How to Correctly Prepare A Provider Appeal
Have you ever submitted a provider appeal that you thought was an easy overturn, but it was still denied and the response was returned with incredibly generic language? Let’s examine your appeal submission.
Studies show that providers appeal only a small fraction of their denials – 10% on average. Often times this is because of the administrative and financial effort necessary to file an appeal. When you submit an appeal, it’s imperative that you do what you can to turn the decision in your favor.
Review These 5 steps When Preparing A Provider Appeal
1
It Should Qualify As An Appeal
Every claim denial is not eligible to be appealed. Each plan defines a provider appeal differently, so make sure that the denial meets the criteria. Common appealable denials fall into the following categories: bundling, mutually exclusive, CPT edits, modifier application or consideration, denials related to an insurer’s Claim Payment or Medical Policy.
2
Follow The Plan’s Provider Appeal Guidelines
These are generally posted on the insurer’s website or available within a secured provider portal. At a minimum, be sure to send the appeal to the correct address, in the allotted timeframe, and with complete information.
3
Don’t Send A Form Letter
I know it’s time-saving to send a general, catch-all, pre-formatted letter, but it’s to your advantage to send a letter specific to the denial and scenario in question. Provide the specific narrative and clearly state the discrepancy. Don’t leave it for the reviewer to have to piece the story together from the documentation. The letter should also include your rationale on why the policy is not applicable for the case.
4
Send Complete Information
The Plan will provide a general list of the elements needed. If there’s something more that would help explain the case, send it. Consider a scenario where the denied service in question is directly related to services that occurred on another date. Include the medical records for all of the dates of service, not just for the date of service you are appealing. Remember, you only delay the process when additional information has to be provided and the appeal reviewed again.
5
Write For The Reviewer
Look in your Provider Handbook or on the insurer’s website to determine who will evaluate and make the decision on every level within the appeal process. If the reviewer is non-clinical, write for their level of expertise rather than inundating them with medical terms that may not be easily understood by a layperson. This concept even applies if the reviewer is clinical. Don’t write in highly specialized jargon or detail that only a physician of the same specialty will know. Don’t write a letter that will require the reviewer to do extra research to fully understand what you’re asking for.
tips
- Check out the article Get Unpaid Claims Resolved before considering appeals. Appeals should really be an option of last resort as this is the costliest method for denied services to be reviewed.
- Once you’ve exhausted the provider appeals process, you may be able to submit a provider-on-behalf-of-member appeal. These types of appeals are entitled to clinical review. Be sure to check the insurer’s rules around timeframes, obtaining member consent, & the types of denials that are eligible.
You have one opportunity to make a first impression. Follow the steps above to make sure that your appeal is given the thought and attention it deserves. Also to elicit a response that’s more than just a template answer and one that’s relevant to your specific appeal.