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!

• Author
• Recent Posts

Chelle Johnson

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.

Latest posts by Chelle Johnson (see all)

• Hidradenitis Suppurativa: Diagnosis, Treatment, and Coding - May 2, 2018
• Rediscover the Lost Art of Customer Service - March 1, 2018
• When Appeals Are Not Enough - November 2, 2017