When it comes to appealing denials, knowing payer policies and regulatory requirements is critical. “Being smarter than your payers is the key to successful denial management,” says Michael Strong, CPC, bill review technical specialist at SFM Mutual Insurance Company in Bloomington, Minn. Consider these tips to ease the appeal process:
1. Give payers what they want.
“Look at the remark codes, and address those specific edits,” says Strong. “Don’t hand them back the same medical record. They’re just going to deny it again.” For example, missing information is a common reason for claim denials. Payers often look for lab or operative reports and won’t pay the claim until they receive this documentation, he adds.
2. Ask for exceptions.
Payer policies aren’t set in stone, and payers may be willing to make exceptions for diagnostic procedures such as labs or x-rays when patients have an abnormal or uncommon presentation, says Tammy Tipton, owner of Appeal Solutions Inc. in Oklahoma City, Okla. For example, she says, many clinical guidelines are more applicable to adult patients and may not be relevant to pediatric patients.
3. Cite regulatory information in the appeal letter.
This includes Medicare Local Coverage Determinations and National Coverage Determinations as well as the Affordable Care Act (ACA), says Tipton.
The ACA, for example, expanded access to external reviews—something that payers don’t necessarily want providers to know, she says. This expansion allows providers who are authorized to appeal on a patient’s behalf to request an external review after they’ve exhausted all internal reviews with a payer. Providers can obtain this authorization by asking patients to sign an assignment of benefits and authorization release, including the ability to pursue appeals on the patient’s behalf.
“I feel strongly that you get a higher quality of review with an external appeal because it’s unbiased, and reviewers are accessing the latest clinical guidelines when making decisions,” she adds. “You also get more detail as to how and why the payer is making certain decisions.”
Also, be prepared to cite the Employee Retirement Income Security Act (ERISA). ERISA allows providers with authorization to appeal on a patient’s behalf to:
- Ask for the specific internal criteria on which a payer is basing a denial. This information goes beyond the denial reason code and can help providers craft a compelling argument to fight the denial, says Tipton.
- Ask the payer to provide the credentials of the reviewer. Demand peer review (i.e., that a physician in the same specialty with the same credentials review the appeal), says Tipton. “The more specialized the treatment, the more critical a peer review is to the review process,” she adds.
- File appeals within 180 days. This may go beyond a payer contract allowing only 30 or 60 days, says Tipton.
“You have to understand all of these regulations, be willing to cite them in your appeal, and demand compliance,” she says