Practice Management Alert

Insurers deny payment for various reasons, some of which may be invalid. However, staff time cannot be spent arguing every denial. Therefore, you need to know key items to spot to determine which claims you should appeal and how to start the process. Steven M. Verno, CMBSI, NREMPT, director of reimbursement for Emergency Medicine Specialists in Hollywood, Fla., and compliance director of the Medical Association of Billers based in Las Vegas, offers these examples of insurers' action that you should consider appealing:

nonpayment of your claim downcoding of your claim refund requests denials based on medical necessity denials that claims services are inclusive in a CPT code "usual and customary" payment lack of authorization lack of timely filing. The first step after receiving a denial is determining whether it is valid, says Sarah F. Mountford, BA, CPC, accounts receivable coordinator for Physicians Business Network in Overland Park, Kan., a company that bills for 34 physician practices. "We usually go back to the medical record and look to see if the services were coded properly. If they were, and they are services for which the payer does pay according to its reimbursement policy, then we appeal," she says. To Call or Not to Call Filing an appeal usually involves writing a letter to the insurer explaining why its action was incorrect. Some practices call the insurer's customer service department, provider representative or appeals department first to try to find out why the claim was denied and resolve the issue over the phone. If you have a good, working relationship with a particular person at the insurer, such a strategy might work for simple problems, Mountford says. But she recommends moving straight to the appeal letter. "We don't make phone calls if we can determine what the problem is. For example, if we know it's an inclusive denial, we know the payer is going to want to see the medical notes, and we're going to have to send a letter of appeal," she says. However, Mountford says a phone call to the payer might be warranted when you don't understand the basis for the denial. Without understanding the reason the claim was denied, you can't effectively argue against it, she adds. If you call the payer, document the name of the person to whom you spoke, the date and time, and the content of the conversation. Such information may become a valuable part of your argument in your appeal letter. The following are five tips for winning an appeal: Address your appeal to the right person. Sending your appeal to the customer service or claims department can result in its misplacement or another denial. "You want to get your appeal to [...]