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When Appeals Are Not Enough

When Appeals Are Not Enough

If you are as enthusiastic about medical billing and reimbursement, it can be vexing when we receive a denial. Here are some tried and true points that every biller should know to address a true appeal correctly.
Know Your Coding
In today’s multitasking office you will often find billers who are certified in both collections and coding. If you are a biller who is not certified, this is an area of growth potential. I would recommend that you consider receiving training and certification in coding. This is as valuable on the back-end for billing, as it is on the front-end for coding.
We need to think of coding as a second language. Being bi-lingual in the medical world is a real asset and will help you when researching a denial. Being able to accurately translate the codes in comparison with the medical records will give you a leg up in accurately addressing a denial.
As part of your appeal process you will need to ensure that all charges were captured correctly and accurately, that all addendums such as modifiers were used correctly, and that all ICD-10 codes are correct and complete.
Know Your Medical Terminology
You will need to master medical terminology. Being able to understand what services were rendered, any complications, or situations that would make an insurance carrier reconsider a denial will be found within this terminology. Knowing medical terminology could be the difference between payment and loss revenue.
Know Your Contracts
To ensure that you are receiving accurate and full reimbursement from your carriers it is critical that you know your contracts. Your contract is a wealth of information. The contract defines the parameters of:

  • Reimbursement Rates
  • Billing Guidelines (CMS or specific to the carrier)
  • Authorization Requirements
  • Limitations or Frequency issues
  • Non-Benefits
  • The benefits are endless!

Knowing what is expected regarding coverage and reimbursement will help you to clearly state your case when an appeal is necessary.
Know Your Websites
I encourage my staff to be the “masters of their webs.” Websites can provide a goldmine of resources, such as up-to-date provider manuals, news or bulletins, forms, addresses, phone numbers, etc.
Know Your Audience
Finally, you need to know your audience. When you complete an appeal for an insurance carrier remember that your final appeal will be reviewed by a staff member at the carrier site who has looked at dozens of other audits that day. Your audit needs to stand out. How do we do that?

  • Keep the wording on your audit clear and concise. Use bullet point and correct formatting to clearly address your validation for the appeal.
  • Make sure that you clearly label the appeal so that the carrier can associate your appeal with the previously-denied claim. Use claim control numbers, dates of service, names, identification numbers, and subscriber information to address this issue.
  • Make sure you attach all items referenced in your appeal. This would include medical records, fee schedules, contract pages, coding definitions (CPT®/HCPCS/ICD10), and pages from the carrier’s manual.
  • When appropriate or requested provide a clean copy of your claim form (UB04 or HCFA).
  • Attach a copy of the explanation of benefits or remittance advice as a reference.
  • Make sure when you put your final package together that the items are clear and any copies are easily readable. Place the items in a logical order so that it is easy for the insurance carrier to follow your narrative.

Knowing your audience by putting yourself in their shoes and providing the information needed to address your reconsideration at their fingertips will improve the success of your request. Remember the person who receives your request at the carrier site is just like you…so K.I.S.S. it! Keep it simple sister!

Chelle Johnson

About Has 5 Posts

Chelle Johnson, CPC, CPMA, CPCO, CPPM, CEMC, AAPC Fellow has over 25 years’ experience in the medical field. She has worked on both sides of the aisle, for insurance carriers as well as the facility and providers. She specializes in the following FQHC, Family Practice, Public Health, Compliance, Ob/Gyn, and Pediatrics. Her past 20 years has been with the County of Stanislaus Health Services Agency in Modesto, Calif.

No Responses to “When Appeals Are Not Enough”

  1. julie newcomb says:

    is there a website that I could get appeal example letters?

  2. Renee Dustman says:

    Julie, There is an article on the AAPC website that may help you: http://www.aapc.com/blog/11879-how-to-write-appeal-letters-that-work/. CMS also offers a form: http://www.cms.gov/Medicare/CMS-Forms/downloads/cms20027.pdf.

  3. Tim Stelma says:

    I would add knowing the NCCI edits. If you identify the exceptions to the edit and that the medical record clearly indicates the procedure code pairing is supported by and NCCI quote (included in the cover letter) you are demonstrating clear knowledge of the issue and it is then just a matter of the auditor verifying this in the medical record for a favorable ruling. State guidelines for Medicaid and LCD’s can also be helpful, as well as CPT Assistant and accrediting organization guidelines. Keep a searchable “scratch pad” of your findings for similar appeals. Auditors do.
    A well constructed cover letter is impressive to an auditor and it makes their job much easier.

  4. Lisa Castillo says:

    Hi Chelle,
    I currently work for a FQHC in Southern Calif. (Fam. Med., OBGYN,PEDs.)can you recommend any ref. books for ICD-10-cm coding geared toward FQHC, and (Fam. Med., OBGYN,PEDs.). I would greatly appreciate it. In addition to any CDI suggestions I may relate to providers.
    Thank you !

  5. Lisa Castillo says:

    I also found your Cesarean-Section scar Coding in ICD-10 article very informative. I will be sharing with my co-workers.
    Thanks again !

  6. Chelle says:

    Lisa…I am glad the information was helpful! In regards to the ICD-10, we use the standard ICD-10 coding book. With FQHC the coding guidelines for the diagnosis do not change so there are no special books or resources for this category.
    Sorry that I did not have something more helpful on the ICD10