Effective appeals often hinge on how you present your case to the insurance carrier. Here are essential guidelines to ensure your appeals are successful:
Be Prepared:
Anyone representing your case in an appeal—whether it’s a coder, biller, office manager, or provider—should be well-informed and equipped with detailed information. They should be capable of discussing the appeal with the payer, explaining the reasoning behind the coding/billing, and illustrating why the claim merits a different treatment.
Craft an Appeal Letter:
Instead of just sending an Explanation of Benefits (EOB) along with a balance bill, draft a clear appeal letter outlining exactly what you want the payer to re-evaluate (e.g., fees, coding denials). While it might take a few extra minutes to write, this can significantly enhance your chances of success.
Correct the Claim Before Appealing:
Submitting an appeal with an incorrect original claim is unlikely to yield a different outcome. Verify the EOB, CPT® coding, diagnoses, and documentation to ensure accuracy. Ensure that you use modifiers correctly. Adding modifiers solely to secure payment might invite accusations of fraud or abuse. After reviewing the claim, make necessary adjustments and document addenda before resubmitting.
Code Based on Documentation:
Adhere to the coding principle: “If it isn’t documented, you can’t report it.” When billing for a surgery, scrutinize the operative note to confirm that all reported procedures were actually performed. Avoid relying solely on the “list of procedures performed” at the beginning of the note, as it might not accurately represent the operations conducted. A thorough reading might uncover separately reportable procedures overlooked in the summary.
Coders should not solely depend on a physician’s suggested coding; they should review the documentation to ensure accurate code reporting. If needed, the physician should amend the record to accurately reflect the service or the patient’s condition.
Avoid Common Errors:
Many denials stem from preventable mistakes such as missing filing deadlines, illegible claims, incomplete patient information, failure to secure pre-authorization, and incorrect or insufficient documentation. These mistakes can be easily sidestepped by meticulously checking claims before submission. Investing this time can expedite your payment and spare the payer from processing denials due to avoidable errors.
