Payer Appeals: Always Verify Delivery, and Be Wary of “Internal” Appeals

When submitting an appeal to a payer, be sure to send it certified mail so you are able to track that the insurance company received the appeal. If you can’t track it, you have no proof it was ever sent (and most likely, the insurance companies won’t either). Be sure to submit appeals in the allowable time frame. This usually is 180 days, but if you are contracted, review your contract to know your appeal rights.

If the insurer does not respond within the allowable time, file a complaint with your state insurance department. The state may ask for proof that you sent the appeal, which is where your certified receipt comes in. Being able to verify the delivery of the appeal is important because insurance companies will face scrutiny from the state if they fail to respond to appeals within the time frames dictated by state law.

The insurer will likely initially pursue an internal appeals process. Before you agree, make sure the internal appeal is mandatory. Only agree to MANDATORY internal appeals; do not accept OPTIONAL internal appeals. If the internal appeal is not mandatory and you file it with the insurance company, one of two things could happen that are not to your benefit:

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  1. The insurance company sends the appeal to an outside vendor to review. Although such reviews are supposed to be independent, often they are not. Appeal decisions of this type frequently are binding, or can be used against you in later appeals.
  2. You could miss the deadline to file with the state. Most external appeals to the state must be sent within a certain time from your final adverse appeal determination letter. Remember: You, just like the insurance company, are on a timeline. You won’t get in trouble for missing a deadline, but you will lose your right to appeal. While you are pursuing an optional appeal, you may be missing out on your time to submit to the state.

 

John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 404 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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