The Job of an Appeals Analyst

The Job of an Appeals Analyst

You billed the insurance company for a service provided by your office only to receive a denial remittance. Is the denial valid? Why wasn’t the claim paid? Who can review the explanation of benefits summary and make a determination? Enter the appeals analyst — an essential position for physician offices, hospitals and clinics, as well as insurers and health plans.

Job Description

A successful appeals analyst knows the many aspects of the healthcare business and has a solid knowledge of coding. In fact, this branch of healthcare relies heavily on Certified Professional Coders (CPC®).

From the time an encounter is billed, to the final determination, there are many hiccups that can occur. It is the job of the appeals analyst to figure out what service was provided; if it was coded and submitted correctly; if the payment policy is appropriate; and if the claim was paid or denied correctly.

A thorough understanding of the CPT®, HCPCS Level II, and ICD-10-CM code sets are imperative in determining if a claim is coded correctly. The skills learned during CPC® training provide the analyst with the ability to navigate the various code books to determine if correct coding has occurred. Additional knowledge of Medicare policies and state Medicaid regulations is helpful in determining the basis for many coverage decisions.

A Day In the Life

The process begins when a provider sees a patient; the service is coded by the office staff, and a claim is submitted to the insurer for payment. The claim is processed and either paid, denied, or pended for additional information. If denied, the provider must determine if the denial is correct or if a corrected claim or appeal is necessary. On the payer side, a review must be done to determine if the claim has the proper determination or if corrective action is needed.

The appeals analyst must evaluate the: who (member/provider IDs, specifics), what (CPT®/HCPCS Level II codes), when (date of service), where (place of service), and why (ICD-10 codes) of a claim for appropriateness.

The next step is to review the payment policy and determine if the reference for the policy is appropriate. Payment guidelines can be based on a variety of references such as Medicare policies, state Medicaid rules, CPT® guidelines, ICD-10 guidelines, the drug label, or a health plan policy.

Thorough review of all data and a response back to the provider completes the process.

Case In Point

Here are a couple of examples that an appeals analyst may be asked to look at:

Example 1

A claim is submitted for a female with birthdate 01/01/2017 for an office visit (99213) on 04/01/2017 by a pediatrician for the treatment of J60 Coalworker’s pneumoconiosis. The insurer denies the claim based on a diagnosis – age policy that states the diagnosis is not appropriate for a member under the age of 15.

Upon review, a 4 month old is being seen for an illness associated with work in a coal mine. A check of the ICD-10-CM code book shows code J60 has an “A” character, indicating this diagnosis is for an adult aged 15-124 years. It is inappropriate to bill this diagnosis for a child based on the guidelines in the ICD-10 code book. A verbal or written explanation is sent back to the provider.

Example 2

A claim is submitted for a Medicare patient, reporting HCPCS Level II code V2756 Eye glass case by a durable medical equipment supplier. A denial is returned stating that this is a non-covered service. The provider appeals, asking why it was denied.

Review of the CMS Internet-only Manual, Pub. 100-04, Chapter 23, Section 30.2, and the national Physician Fee Schedule, reveal the answer. Code V2756 is classified as a Status I (Invalid for Medicare) code; the service was denied appropriately. While this is a routinely denied service by Medicare, the analyst should review further to be sure that state Medicaid or client requested polices do not exist that would allow the service.

With a bit of investigative work, coupled with a solid understanding of resources and guidelines for correct coding, an answer to “Should this claim be denied?” can be easily answered.

Kimberly Hartley

Kim Hartley, CPC, AAPC Fellow, has 30+ years of experience in the healthcare industry. Her career began with the local Medicare carrier and she is now a policy inquiry analyst with Cotiviti Healthcare.

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One Response to “The Job of an Appeals Analyst”

  1. Andreea Mann,CPC says:

    Excellent article!! I am currently studying for my 2nd credential, CPMA. The role of an appeals analyst seems very interesting to me.

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