The Changing Face of Appeals in Medical Billing

Gone are the days when denied claims were dealt with in either of the following 2 ways.  Your clinic handyman takes a photocopy of the rejected claim and stamps “APPEAL” in big bold letters or some such thing and sends it via the UPS to the insurer.  Or else, against your better judgment, you call up your patient and dump the matter on his/her head.   Now, only one outcome was finally ensured in the above circumstances.  “You didn’t get paid”.

Appeals Process

Practices now seem to realize the futility of the above and do make some genuine effort at tackling the same.  They have dedicated templates for appeal letters and have medical billing software which ensures that appeals are submitted within the respective timeframes for each of the payers.  Despite this recent trends quite clearly indicate a shift towards less and less of the appeals process enjoying a successful outcome.  The reasons for this are many.

The handyman we had mentioned above may have been replaced by the practice manager.  This is good, but not good enough in many cases of denials.  It has been seen that medical billing staff trained specifically to deal with particular denials stand a better chance of securing payment from the payer.  Of course these staff may have been cross-trained in other domains of medical billing, but even so they are better equipped to handle the appeals process than your practice manager, who may not feel comfortable with the entire thing.

Denial of Claim

Another major reason for the appeals not working is the lack of appropriate supporting documentation to revive the case.  Most often than not clinic staff make only cosmetic changes to the resubmitted claims and do not address the root cause as to why the claim was denied.  This could be because a preauthorization was not obtained or perhaps a referral was not done, etc.  In such cases the respective documents need to be compulsorily submitted during the appeals process.

Distinct Service

Or it could be that the payer deems the treatment experimental or questions the necessity for a separate payment of a distinct service.  In such instances it really helps if similar cases paid by Medicare & Medicaid are quoted as supporting material.  Also it pays to have the physician write a paragraph or two elucidating the need for that separate service.

Dealing With Denials and Appeals

All of the above measures are less likely to happen in a clinical setting than say at an outsourced revenue management expert service.  This is because such services employ personnel with tons of experience in dealing with denials and appeals and are immune to the rigor that the appeals process entails.  A practice thus stands a better chance at winning the appeals process when channeled through a revenue management expert.

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