Practice Management Alert

Brush up on tips to turn that stack of denials into cash your practice deserves.

Finally, a chance to pierce the veil: What are payers thinking when they see your denials? How can you adjust your appeal so payers pay attention - and the money your practice deserves?

Learn how to communicate better with payers from Angela Boynton, RHIT, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-I 010/ C 10 C d T, principal at Boynton Healthcare Management Solutions LLC in Shrewsbury, Massachusetts.

Take on Denials In-House

According to the Medical Group Management Association (MGMA), it costs between $25 to $30 to manage the average denial. Consider how many denials you've had stacked in the back, and let your eyes light up with dollar signs - there's a lot of money that could be yours.

Don't be tempted to let an outside vendor take on your denials for you, or at least run some quality assurance to make sure you can take them at their word. You know your practice and your cases best, so taking on your own appeals could be the easiest way to get paid.

Think in Specifics, and Prioritize Documentation

Appeals are time-consuming, so make sure your appeal is fully ready to go the first time. Don't fall for the convenience of a form letter for appeals; write out the specifics and include documentation. As a provider, saying "pay me" is not enough to make a case.

When Boynton worked for payers, the canned letters got denied immediately, she says. "If they were better written and supported, they would have had a chance of getting paid."

Learn the Payer System So You're Prepared

No two payers have the same cycle for how they deploy their edits, Boynton says. But most payers begin again with the New Year. Now is the time to get your affairs in order so you're ready for the next cycle.

It sounds obvious, but make sure whoever tackles denials - and practice finances, generally - actually reads the payer contract. Because no two payers approach appeals in the same way, you need to make sure you tailor each appeal to the particular payer's requirements, Boynton says.

"The more time you spend preparing, the less time you spend fighting," she adds.

Unsurprisingly, the stakes are bigger with higher dollar claims, so consider your game plan: high dollar and more effort or not much effort for not much money.

Include Your Claim Number

Generally, most payers have claims go through a computer with an "optical reader program" first, Boynton says. After that, your claim should be seen by a person, but the knowledge base may differ greatly from person to person.

"The problem is that the people usually are not coders. They may not even know what a medical code is," Boynton says. If they can't make sense of your claim, often the payer will suspend it.

Every payer's appeals process is different, but generally, the knowledge base differs at each level. The people who take the first pass at the appeal may only have a high school education; nurse coders or auditors may take the second pass, and a medical director may see it if the claim sees a third round.

"You'd be surprised how many appeals come in and nobody tells me what they are appealing," Boynton says.

Some appeals don't even have a claim number! Don't make that elementary mistake.

"An appeal reviewer who is under a quota is not going to spend time tracking down that claim number," Boynton adds.

Go for the Nuts ... and Bolts

Be exceedingly logical and matter of fact in your appeal letter; avoid emotion at all costs, as it does nothing to help you.

"Too many providers are afraid to cite the regulation," Boynton says. But if you cite the regulation, then you force the payer into a dialogue about the nuts and bolts. If they argue with you, you can immediately ask what regulations they follow and why, she points out.

Asking for specific regulations may resuscitate their interest and attention. "At the end of the day, the only thing that might get them truly engaged is citing the law," Boynton says.

Citing compliance, when applicable, is also a good way to win your appeal, she adds.

Document Consistently

Keep records of when you talk to a payer, who you speak to, the date and time, and what you discussed. And get into the real-time record keeping habit for your practice, as well. The denials/appeal process is already chaotic, but careful notes can save you time and boost your success rate.

Tip: If payer keeps "losing" documentation, send it certified mail, Boynton says.

Much of preventing denials is common sense, along with other time and business management issues like work flow. Having business acumen helps. But so does consistency and documentation; track denial trends so that you can correct systemic errors that are causing them.

Note: If a payment is denied because a payer says that the treatment is experimental or investigational, do your research. Other states may say that that particular treatment works for that issue, and if you can find the data, you have that much more evidence to support your own claim, Boynton says.

Rely on ACA Rules for Backup, for Now

The Affordable Care Act (ACA) includes rules to force payers to become more transparent about their evaluations and processes.

"Payers change their rules more than most of us changeour underwear," Boynton jokes. But knowing the laws, even just the basics, can be a huge help in securing payment.

Incorporate ACA language into your letters, too, such as "In order to seek a more transparent process ..." Boynton says. Using those buzzwords will make your letter stand out as having been written by someone who knows the rules and knows where to aim for successful results.

If you get a "no" from a payer and they don't provide you with a reason, ask for the reason. At the very least, asking why may bump your claim into the hands of someone who has more education and experience.

Don't Forget IROs Are an Option

Federal law §147.136 Internal Claims and Appeals and External Review Processes says that consumers (and payers) have the right to submit claims to an independent review organization (IRO) even after the appeals process is exhausted.

This is a win-win for consumers, providers, and providers, according to a white paper on "Mastering External Appeals" released by URAC, a nonprofit based in Washington, D.C.

Submitting a claim to IRO is ostensibly less expensive and less of a hassle than litigation for everyone involved, and the opportunity provides more protections for consumers. Plus, IROs are inherently neutral, as they have no financial stake or conflict of interest.

Don't forget: IROs are binding, Boynton emphasizes. Once a claim has been sent to an IRO, you cannot pursue other avenues.