Tips for Successful Insurance Claims Appeals

The word appeal is frequently considered a dirty word within the walls of Sceptre Management. Generally, by the time a payers’ requirements for appeal submission have been met, the claim in question is past due and the chances for obtaining full reimbursement have decreased. The entire appeal process is labor intensive, and success rates are generally not in favor of the provider.

We teach our staff to avoid needing to file appeals by filing clean claims, being proactive in follow-up efforts, and working with the payer’s customer service supervisors and provider relations representatives to obtain payment in a timely manner. There are times when the payer will deny correct payment of a claim, regardless of a biller’s best efforts. In these instances, filing an appeal may be necessary.

Some time ago, one of our dialysis facility clients started receiving underpayments from one of the payers they were contracted with. The contract between the payer and our client specified the payer would reimburse a set amount for each dialysis treatment in addition to providing separate reimbursement for several ESRD specific medications. The underpayments were a result of the payer no longer reimbursing for the medications specified in the contract.

The biller working on this account was able to work with the payer’s contracting representative to get the facility’s contract re-loaded into the payer’s system. All the claims we submitted after the contract was reloaded were processed according to the contract. However, after working for several months and following every available avenue to obtain full payment, the biller had yet to receive full reimbursement for the claims the payer had originally underpaid. The biller filed appeals for each of the claims that had been underpaid and after a lengthy appeal process, the payer overturned their original processing and issued payment according to the dialysis facility’s contract.

Tips for Successful Appeals

Filing an appeal is a formal request to a payer to overturn or modify a decision they have made in processing an insurance claim. A good appeal demonstrates why a denial or underpayment issued by a payer was incorrect. Providing all information pertinent to the claim in question in a concise manner increases the likelihood the appeal will be successful.

Each payer has their own rules and guidelines that should be followed when submitting an appeal. Prior to filing an appeal, speak with a representative from the payer and identify all the requirements the appeal will need to meet. You may find it helpful to take detailed notes of the instructions you receive for filing an appeal and ask as many clarifying questions as you feel are necessary. In most cases an insurance company’s appeal requirements fit into three basic categories: the appeal letter, medical records, and supporting documentation.

Appeal letters should be concise, professional, and as short as possible. If an appeal letter is too long, you run the risk of the letter reader getting bored and not reading pertinent information. Appeal letters should include the payer’s reason for denying the claim, an explanation of why the payer’s denial is invalid, an explanation of why the payer should pay the claim, and the desired outcome of the appeal.

In addition to explaining to the payer in the appeal letter why they should reprocess your claim, you should include documentation to support your argument and desired outcome. When appealing claim denials related to medical necessity, attaching complete medical records to an appeal gives the payer a clearer understanding of why services were necessary. Other types of supporting documentation that may be helpful to include in an appeal are copies of the provider’s contract with the payer, pertinent sections of the payer’s provider manual, proof of timely filing, etc.

After putting effort into compiling and submitting an appeal, it would be foolhardy not to follow up with the payer to ensure the appeal is given fair consideration. Timely and persistent follow-up is almost as important to getting an appeal approved as the quality and completeness of the appeal itself. You may find it helpful to keep a copy of the entire appeal on hand until the payer completes the appeal processing. Billers should also keep detailed notes of any communication with the payer regarding the processing of the appeal.

Sarah Tolson is the director of operations for Sceptre Management Solutions, Inc., a company specializing in billing for outpatient ESRD facilities, nephrology practices, and vascular access. Your questions are welcome and she can be reached at stolson@sceptremanagement.com, 801.775.8010, or via Sceptre’s website, www.sceptremanagement.com.