Practice Management Alert

Even when you think you-ve done everything right -- double-checked diagnosis codes, included detailed patient information, gotten a signed advance beneficiary notice (ABN), etc. -- Medicare may still deny your claim. When you know that Medicare should pay the claim, use these checklists to get all the money you deserve.

Helpful hint: You don't have to appeal a denial if you find you-ve just made a mistake on the denied claim, according to CMS. Just ask your carrier to reopen the claim so you can correct the error.

Checklist 1: Determine the payer made an error

If you receive a denied or underpaid claim, you first have to make sure that the denial isn't a result of the way you filed the claim. To do so, follow these steps outlined by Barbara Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders in Salt Lake City:

Once you-ve determined that the payer made an error, you can write a letter expressing why you think your carrier should pay the claim. Just remember that Medicare requires that you file your request within 120 days of the date of the initial determination notice. Check with private payers to find out their time limits.

Checklist 2: Follow Medicare's style

Medicare prefers that you follow certain guidelines when you write appeal letters, so start off on the right foot by writing your letter correctly. Medicare needs to handle these letters as quickly and efficiently as possible, so correct style will help the reviewer focus on your appeal rather than getting tripped up on your style.

Be sure to use the following guidelines:

Checklist 3: Use the correct letter format

Like correct style, correct formatting allows the reviewer to get to the heart of your letter -- your appeal -- more easily. Implement these style conventions to ease the appeals process:

- Associate the code with the procedure name when citing procedure codes.

Checklist 4: Structure your letter content wisely

Now that you-ve determined you have a denial to appeal and set up your style and formatting correctly, you should focus on the content. Make sure you include the following information in your appeal letter:

Find out more: These checklists should help you get the ball rolling with your appeal. Medicare's appeals process is involved and has many levels. Do your research ahead of time to make sure you-re armed with the knowledge and organization you need to get paid.

You can find more information regarding these checklists on Medicare's Web site at http://www.cms.hhs.gov, as part of the Medicare Claims Processing Manual. In this manual, you-ll also find additional information about the different levels of the appeals process. These levels are:

Bottom line: Getting the money you-ve earned is a top priority for billing departments. Stay on top of the tricky appeals process by referring to these checklists whenever you-re hit with a denial or an underpayment comes your way.

Stay tuned for more appeals tips -- plus a sample appeal letter -- in the next issue of Medical Office Billing & Collections Alert.