Manage Revenue with Diligent Appeals

By Julie Bos, CPC

I have experienced all types of office settings, from very large billing services to a one-physician practice, and the same problems confront them all. It’s always the easy money—the low-hanging fruit—that gets attention, while the rest seems to be left to rot on the tree. I believe that a provider deserves to receive appropriate compensation for all services rendered. In the following true story, you will see how knowledge of the appeals process yielded a large amount of money that otherwise would have gone unnoticed and unpaid.

Let the “Appealing” Truth Be Told

In mid-2012, a behavioral health provider contacted me because they were being audited by their state Medicaid agency. The state agency told them that having a CPC® on their team would lend credibility to their billing.

After an internal audit, during which I found and corrected coding and billing errors, I noticed that the state behavioral health Medicaid payer was denying full reimbursement on home-based code H0004. The clinicians would typically spend 2-3 hours at the client’s home, but were being paid for only one hour. Per the coding guidelines in the Uniform Services Coding Standards Manual (USCSM), H0004 should be billed in 15-minute increments, with a minimum of 8 minutes and no maximum.

I questioned the office staff and administrator why they hadn’t been paid for the extra hours. They explained that when the behavioral health Medicaid payer was initially contacted, they were told “plan provisions” determined that only one hour was payable. Being timid to question a state agency further—especially during the middle of an audit—they gave up.

If It Doesn’t Sit Right, Research and Appeal

After the auditing issues were corrected, and a new plan for coding and billing was established, I turned my attention to the problem with Medicaid. The state agency’s answer still did not seem right. I researched the USCSM and the related website and found nothing to support their denial of H0004 claims beyond one hour. I started appealing for additional payment.

An appeal is simply a request stating that you don’t think a payment or denial decision is valid based on information you have available to you, and is submitted with the explanation and supporting documentation you used to determine this.

Included in the appeal was the documentation gathered from the state Medicaid agency manual and website showing where I thought the code should be paid for the full time spent with the client. I also sent records documenting the service and time spent with the client, and a cover letter clearly explaining my reason for requesting additional payment.

In return, I received denials. The denials stated that the claim was paid according to “the plan provisions,” and included the names of two top-level executives who reviewed the appeal(s). I again looked through the “plan provisions” information in the USCM and its website. I also reviewed the information given in the patient plan.

If It Isn’t in Writing, Don’t Take No for an Answer

Once again, I couldn’t find anything in either the provider manual or the patient plan to justify their denial. I started making calls. I called the claims department. The customer service representative told me the payment decision was upheld because of “plan provisions.”

“OK,” I said, “Please show me where it says there is a time limit on this code.” I explained that I didn’t want to waste my time, or theirs, on a mistaken appeal, but that I couldn’t find anything showing a limit for H0004.

My question was initially met by silence. Then, I learned the customer service representative could only access the information showing in the computer, and had no real knowledge of why and how claims get paid or denied. She could not help me.

I asked to speak with a supervisor. I gave the name and credentials of the executives from the denial letter, which stated they had reviewed the claim, and if there were any problems to call them. This request also resulted in silence. I again explained the situation, and asked the supervisor to get me in touch with someone who could direct me to the place showing the limit for H0004.

I was finally transferred to the voice mail of one of the executives named in the denial letter. I requested for him to get back to me with documentation supporting the denial decision. He returned my call and said that he was unable to give me the backup for this denial, but he would see what he could find.

I never heard from him again, so I started second-level appeals.

Stand Your Ground

A second level appeal is used when the initial appeal has been upheld (as in this case), but you still disagree with the results. There should be solid evidence to support and justify the time and effort necessary for this type of appeal. In this case, there was solid lack of evidence on the part of the agency, as they could not provide me with documentation supporting their case.

I sent 24 pages of documentation for each claim—from the payer’s own manual and website, for both provider and patient—defending my position that there was no time limit for the code in question. I requested that the payer prove its position and provide documentation.

In the meantime, I received a phone message from the local provider representative stating that the issue was being reviewed, but the system was “broken.” To me, this was a serious problem. How long had this been going on? Insurance agencies are quick to let the provider know when he or she is not compliant. Providers need to hold insurance agencies to the same standard.


A few weeks later, checks started to arrive. The state Medicaid agency had realized its error and began reprocessing claims from Jan. 1 forward. To date, this one appeal has produced over $11,000 in revenue for this one provider. And this is only for claims January through March.

What excites me is that not just one provider will benefit from my appeals. A problem was identified, questioned, and shown to be in error, and now the state agency must review their entire claims processing for this code on all claims paid incorrectly. Whether the agency will reprocess and pay out additional money automatically, or wait for individual offices to send appeals, is unknown. If the agency does the correct thing and automatically processes previously denied claims, many providers will receive additional revenue because I took a stand.

Knowledge + Diligence = Money

Due to my client’s lack of knowledge, they gave up. They were intimidated by the ongoing audit and the prestige of a government agency. One knowledgeable person with a firm grasp on the appeals process managed to net tremendous revenue that would’ve otherwise gone uncollected. My value to this one entity has grown tremendously.

By persevering in the appeals process, you make yourself a more valuable asset to your employer. More value equals increased earnings.

Lessons to be learned:

  • Know the appeals process.
  • Provide supporting documentation.
  • Don’t give up if you know you are right.

Julie Bos, CPC, earned her CPC® certification in 1994 and spent the next 19 years in multiple specialties perfecting her medical billing and appeals skills. As owner of her own revenue management business based in Denver, Colo., she works at attaining the maximum revenue for her clients.


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