If youâ€™ve received a claim denial from a patientâ€™s insurance provider and you have determined that the claim was submitted without errors, you should appeal the denial. In our webinar last week on Effective Appeals in Medical Billing: Breaking Through the Barricade to Get Paid featuring speaker Elizabeth Woodcock, she revealed that 75% of appeals result in denials being overturned â€“ and paid.
Whether your denial was based on a billing dispute or a medical necessity determination, your claim appeals are a legal process and require diligent preparation.
The Patient has the Authority
When you appeal a claim, you are appealing on behalf of the patient and not the physician or provider. As the provider or medical biller, you are not authorized to appeal an adverse benefit determination without a signed authorization from the patient. An Assignment of Benefit form is not sufficient authorization, as it only authorizes the claimant to receive payment from the payer on the patientâ€™s behalf.
With authorization secured from the patient, you have specific steps to follow in order to submit a claim appeal. Remember, the appeal is a legal process. This means that at some point you may have to use the court system. Any information that you use in your appeal may become evidence in court and may even be used against you. Before you proceed with a claim appeal, you should determine how far you wish to take your appeal.
When you are filing a claim appeal, you should be as prepared as a lawyer going to trial. The insurance company or payer that denied your claim should have already disclosed to you the nature of the adverse benefit determination. That communication should clearly state the reason that you were denied payment or not paid in full, including the following information:
- Reason(s) for the denial
- References to the plan provision on which the denial is based
- AÂ description of the information/documentation required to appeal the claim
- Procedures for appealing a decision.
You may request additional documentation, including copies of the patientâ€™s benefit manual or any specific plan rules, rate tables, fee schedules and criteria used to ensure that the plan rules were consistently applied to your claim. The payer may also hire medical, occupational or other experts to obtain specific knowledge regarding conditions of your claim. The payer is not required to disclose the identity of these experts, but must provide that information when requested by the claimant.
Prepare and File Your Appeal
By comparing the documentation provided to you by the payer with the documentation you already have regarding the patient, including chart notes, you should be able to determine where the problem lies. Draft a strong appeal letter summarizing all relevant information regarding the claim in question. Stick to the basics, avoiding any information that is not essential to the claim. File your appeal in a timely manner, and make note of the date in a file you create specifically for this claim. Follow up regularly and try to speak with the same people whenever you contact the company. With documentation and diligence, your adverse benefit determination can be overturned and the bill paid.