Filing Effective Appeals

Medical insurance claims are often denied for a variety of reasons and a good biller must learn to file an effective appeal in order to limit write offs and keep aging claims to a minimum.  Denial decisions can often be overturned with a well written appeal.  When an error is made on the claim, often an adjustment can be filed to fix the problem but appeals are filed when a claim has been denied or paid incorrectly and there are no corrections that can be made to the claim.

There are several different methods of filing an appeal.  Some appeals can be done over the telephone while some appeals can be done through the insurance carrier’s website.  Other appeals must be filed on paper.  The secret to getting a denied claim paid by using an appeal is to do it right and to attach the necessary attachments to prove your case.

One of the most important things in filing an appeal is that the problem has not gone a long period of time with no follow up.  If you filed the claim nine months ago and never called to check to see what happened you have likely forfeited your appeal rights.  But if you have been experiencing an issue with a claim and have been acting on it on a regular basis, you have a good chance of getting it reversed and paid.  But you should make sure you have documentation showing the actions that have been taken.
Keeping track of the ongoing communications with the insurance carrier regarding the claim you are trying to appeal is very important.   We keep notes of every phone call, fax, or letter regarding a problem claim.  We note who we spoke to, what we were told and the date the communication took place.   We keep these notes in our practice management system on the claim encounter.  This information is critical to the successful overturn of a denial decision.

When it comes time to write the appeal, we determine the appropriate method of submitting it – either on the insurance carrier’s website, over the telephone, or in a letter.  We state all the facts of our attempt at correcting the problem and why we disagree with the determination.  We also attach copies of our records of the communication as well as any other attachments regarding the appeal.  For example, if a claim to a Medicare Advantage Plan is denied stating it is not a covered Medicare expense when we know that it is, we attach a copy of the Medicare LCD or NCD to support our claim as well as a copy of a Medicare eob showing payment for such services.  Of course we black out any PHI.   When you file a well prepared appeal and have good documentation to support your case, generally the denial decision is then overturned.

Common Reasons Claims Need to Be Appealed:

•    Timely Filing
•    Non Covered Service (when you believe it should be)
•    Requested Documentation not received
•    Reimbursement is not correct (claim paid as specialist with higher copay when provider is the patient’s PCP)
•    Services were bundled when they should not have been (insurance carrier didn’t recognize modifier(s))

Reasons a Claim Would Need An Adjustment instead of an Appeal
•    Claim was submitted with incorrect insurance ID number
•    Modifier was incorrect or missing
•    Date  of service was incorrect
•    Diagnosis was incorrect
•    Incorrect rendering provider was listed on claim
•    CPT code was incorrect


One Response to “Filing Effective Appeals”

  1. Denise Sikora Says:

    This is excellent information. Thank you for taking the time to discuss a topic that is of great interest to me.

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