F R O M T H E F I E L D
The Real Deal About Appeals, Part 2
By Nancy Clark, CPC, CPC-I
Last month in BillingINSIDER we discussed how to prepare for your appeal for an inappropriately denied claim. We discussed reaching out to the payer and learning why the claim was denied. Now it's time to write the appeal letter. A direct, concise approach works best, using the following format for most commercial carriers:
- Physician or Practice Letterhead
- Date of Appeal
- Insurance Carrier Name, Address, and Attention Line
- Identify the Claim
- Claim Number
- Patient Name and Date of Birth (DOB)
- Patient Identification Number
- Date of Service
- Provider's name and identifiers:
- NPI, Tax ID, and/or Insurance Company Provider Number
- Additional items, depending on the carrier and situation, include:
- Place of Service (POS)
- Subscriber name and date of birth, if it is not the same as the patient
- Date of claim determination
- Amount billed and amount in dispute
- In the body of the letter:
- State what is being appealed and why the insurance company denied the procedure.
- Explain the rationale for your appeal.
- List the supporting documentation included to substantiate the facts. A bulleted, easily readable format is best.
- Summarize why the enclosed documentation supports payment of the claim.
- Conclude by thanking the representative for his or her time, and offering your contact information in the event that clarification or additional documentation is required.
- List the specific enclosures that are accompanying the appeal, including:
- Explanation of Benefits (EOBs)
- Prior authorizations
- Any pertinent correspondence from the insurance company
- Medical records, operative notes, letter of medical necessity
- Remember to:
- Use certified mail to obtain proof of delivery.
- Retain the fax confirmation if you have sent the appeal via facsimile.
- Include the explanation of benefits (EOB).
- Include any pertinent correspondence from the insurance company, such as a prior authorization.
The appeal process is not finished. Set reminders to follow up on receipt of the appeal and continue to monitor the review process.
For straightforward appeals, such as the addition of a modifier to a procedure code, the claim may be paid fairly quickly. However, if the medical necessity of the procedure is in question, a detailed review by a medical specialist or medical director may be required. Due to the volume of appeals compared with the number of medical review specialists at a given institution, the process may take considerable time.
Ensure you contact the appeals department directly at regular intervals to verify your claim is going through a proper and timely review process. Keep this information with that claim's appeal file, and the status of the claim will always be readily available.
When the claim has been processed, evaluate the payment to ensure it was properly adjudicated in accordance with the physician's or facility's contract, and the patient's contracted benefits.
Here is a sample appeal letter you can use for most insurance carriers. A redacted appeal letter for medical necessity may help you improve your claims appeals.
G O O D T I P S
Update Your Fee Schedules Regularly
By Wendy Grant, CPC
Payers update their fee schedules annually, and providers should do the same. To be profitable, you should cover expenses by keeping your fees in line with your current market area. It is not too late if your practice has failed to update your fee schedule—if you act now. Most payers have a timely filing period for adjustments, which is a limited time to capture any additional monies due.
First, perform an analysis of the fee schedule you use. Next, review the current year's fee schedule for all common payers to understand which CPT® codes were affected with increases. The majority of changes are small (plus or minus $.01-$1.00), and many codes may result in no change at all. When you find significant increases, appeal to the payer for a monetary adjustment.
Run a report by payer from your system for all of those codes where you saw increases in the fee schedule. When you have identified which patient accounts need adjustment, print CMS-1500s for each of those claims. Group the claims by payer. Attach a cover letter for each, advising the payer the claims need to be reprocessed due to the increase in your fees. You should send them to the attention of "Claims Review" so they won't be denied as duplicates.
Perform some housekeeping duties within your own billing system. The "newly increased" CPT® fee will need to be keyed to each patient's account for which you are requesting monetary adjustments. The previously underpriced charge will then be voided. If you don't perform these accounting adjustments to your patient accounts, you may end up with an inappropriate credit when you receive additional monies from the payer. You wouldn't want this credit to end up being refunded to the patient. It belongs to the practice!
F E A T U R E D S T O R Y
Consider the Impact of ICD-10 on Billing
By Brandi Tadlock, CPC, CPCO, CPC-P, CPMA
Much attention has been given to how ICD-10 will affect provider documentation, electronic billing systems, and coders tasked with learning the new code set. Whether services will be considered "payable" hinges on the medical necessity of services as defined by each payer. It will prove just as important for providers to consider how the added specificity available with ICD-10 affects coverage criteria in the near future.
Assessing ICD-10's impact on reimbursement is a daunting task if based solely on the sheer volume of new codes. To complicate matters further, medical coverage guidelines often lack uniformity from one payer to the next, as Rhonda Buckholtz, CPC, CPMA, CPC-I, AAPC's vice president of ICD-10 Education and Training, pointed out at a hearing for the National Committee for Vital Health Statistics (NCVHS) last November:
As we are all aware, no two plans are alike and even within each plan itself the different family of offerings make the frustration of not having consistent guidelines and edits an administrative burden most practices simply can't afford.
Most large payers detail coverage protocol online, and many provide a list of diagnoses indicated for coverage for the service mentioned in the policy, listed by their ICD-9-CM code(s). The key to finding the information is knowing where to look:
- Medicare has NCDs and LCDs.
- Aetna has "Clinical Policy Bulletins."
- UHC's medical policies are known as "Coverage Determination Guidelines."
- Blue Cross simply calls them "Medical Policies."
- Medicaid varies state-by-state, as always.
To prepare for the impact ICD-10 will have on future reimbursement, understand how payers plan to amend coverage guidelines to account for the greater specificity included in the ICD-10 code set. Will the range of covered conditions for a given service be expanded proportionately to allow for the same basic coverage (with more codes), or will payers be revising their policies to require more specificity for conditions to be considered "medically necessary?" And, when will information regarding specific changes to coverage criteria (as it pertains to ICD-10) be available for providers?
Medicare provides a crosswalk of all ICD-9 codes listed in coverage determinations to corresponding ICD-10 codes via general equivalency mappings (GEMS). Other payers may not follow suit. To find out how other payers are planning on addressing these changes, I checked with Aetna, Blue Cross and Blue Shield (BCBS), and UnitedHealthcare (UHC).
Both Aetna and UHC predict ICD-10 will reduce administrative burdens on both payers and providers by reducing requests for additional clinical information to process claims or precertification.
James Cross, M.D., head of Aetna National Medical Policy and Operations stated, "Some procedures may no longer require precertification at all because we will have the information we need through the codes." He also acknowledges that Aetna's coverage criteria likely will be affected by the level of detail available in ICD-10's code descriptions because "they allow for more precise information in the clinical policy bulletins."
UHC's website is the most candid about the reality of the coming change. Because only 5 percent of ICD-10 codes correspond one-on-one with ICD-9 codes (including both CM and PCS), the number one problem UHC anticipates stems from the lack of an industry-accepted crosswalk (followed closely by claim denials due to errors in data entry):
Without standardization, it is likely that physicians, health care facilities and payers will create different versions of mappings and crosswalks. Imperfect mapping will affect processing and analytics that impacts revenue, costs, risks and relationships...
Because there is more than eight times the number of ICD-10 codes, the amount of errors may increase as medical billing, patient accounting, coding specialists, physicians and claims specialists adjust to the complex new system. As a result, denial rates may rise due to inaccurate coding and crosswalk misinterpretations.
Although UHC stops short of detailing specifics on how it plans to adapt policies to ICD-10, they do allude to some of the changes providers can expect to see:
Payers will need to evaluate and reconfigure current benefit plan structures to identify the changes in coinsurance, copayments, deductibles or other plan elements that are more specific to the precise ICD-10 diagnosis codes...
UnitedHealthcare will evolve its payment methodologies to support health care quality as it gains experience and data with the ICD-10 codes.
Aetna expects to publish the new clinical policy bulletins on the publically available clinical policy section of Aetna.com several months prior to the ICD-10 implementation date.
A quick internet search showed that some Blue Cross plans, such as BCBS of Florida, have already begun to incorporate ICD-10 codes into their medical policies. The crosswalk appears to be straightforward on this Liver Transplant policy; the 82 ICD-9 codes indicated for coverage correspond closely to the (approximately) 258 ICD-10 codes listed beneath them.
Providers should monitor contracted payers during the coming months to prepare for changes, which are just over the horizon.
FROM THE FIELD is thoughts and experiences from you the reader. If you have any tips, ideas, case studies, or just anecdotes please submit them to us for future editions.