How To Write Appeal Letters That Work!

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  • In Billing
  • March 23, 2011
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The complexity of federal regulations and insurance plan rules continues to wreak havoc with the physician revenue cycle. Consider the effect on your practice of expanding global periods, bundling edits, Local Coverage Determinations (LCDs), and non-covered procedure lists. Even the savviest medical billing staff must fine-tune the appeals process to prevent it from becoming a lengthy battle. Knowing how to write an effective appeal letter greatly enhances your practice’s chance of getting paid for initially-denied or underpaid claims. Use the following list to improve your appeal letters and increase revenue:
1. Understand the content of your EOB/ERA. Ask yourself:

  • Is the denial/underpayment due to bundling edits such as Medicare’s Correct Coding Initiative (CCI), an LCD, or a procedure’s global period?
  • Did the insurance plan only pay for one procedure when two were included on the claim form?

Why this is important: The language of the appeal letter argument should address the insurance plan’s reason for denial or underpayment.
2. Know where to locate the insurance plan’s medical health and coverage policies. Find out whether the insurance plan’s policies conflict with the accepted policies of the American Medical Association or your practice’s specialty association. Check whether your contract with the insurance plan includes exceptions, and if the patient’s benefit plan covers the procedure.
Why this is important: Referencing the appropriate policy and regulation language within your appeal letter provides the greatest chance of success. Supply all supporting documentation with your letter so the appeal reviewer has all information at his or her fingertips.
3. Be familiar with the insurance plan’s appeal process. Know which forms and time frames are allowed for submission, follow-up, and response. What additional levels of appeal are possible if you’re denied?
Why this is important: Treat each appealed claim like a project. Set expected milestones, including the date of appeal and expected response time. As each claim goes through the appeal process, track the level of the process it’s in, as well as the deadline for filing. Note: If you have exhausted all avenues with the insurance plan or feel that the insurance plan has unjustifiably denied your claim, file an external review with your state or federal insurance commission or regulatory agency.
4. Make sure the physician’s documentation is clear and complete. Simply circling a CPT® or ICD-9-CM code on a superbill does not provide supporting evidence that the procedure was performed—or medically necessary. Make sure your physicians document as much information as possible in the medical record to support any necessary appeal efforts.
5. Include as much information within the appeal letter as possible. Include 1) all patient demographic information; 2) all pertinent insurance information; 3) date of service; 4) place of service; and 5) EOB/ERA denial code and reason toward the top of your appeal letter. Then include 1) Proof of medical necessity of the procedure; 2) research from the insurance plan’s medical policies, your specialty society information, the patient’s benefit coverage, etc.; 3) copies of all radiological, lab, and pathology reports; and 4) any other information. Keep the letter professional.
6. Lastly, send the letter via certified mail so that you have record of its receipt by the insurance plan. As many of you know, two of the most common phrases used by insurers are, “We do not have record of that claim on file,” and “We never received it!”

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