When defining medical necessity, most payers base their payment off of evidence-based medicine and guidelines of appropriate medical care by the appropriate healthcare provider.  

Some health coverage denials, such as when a healthcare provider enters a wrong code on a claim form, are simple mistakes that are easily resolved. But there are other issues can be much more difficult – centered on complex medical questions like whether a certain medical treatment is appropriate. Battling health insurers when they refuse to cover certain treatments can be exasperating, time-consuming and costly. But, through a disciplined denial management program, providers can fortify their cases and better address complex denials.

Build an Appeal Package to Overturn Denials

Online tools give your staff access to the “best case” throughout the medical claim appeal process.  Briefs for specialty organizations, payers guidelines and rules, local and national coverage determinations, and use-case template appeal letters create an appeal package.  These generally provide invaluable time savings while also improving overturn rates. Plus, since denial management is an ongoing project, these tools also assist as you keep your processes continuously up-to-date and reflective of the ever-changing payment policies of insurers.

Keep Appeal Letters Organized

Organizing appeal letters can help ensure they go out in a timely manner. Using a template that contains all pertinent information that would be considered “necessary and consistent,” such as the account number, medical record number, patient name, visit dates, and both the original MS-DRG and any changes.

Provide Appeal Proof

We asked our VP of Clinical Operations, Deborah Horne, about what she sees when helping providers transform their approaches to managing denials and filing claims in the first place.

Many appeal letter arguments will not be considered because the wording simply says, ‘The service was provided by a physician and he/she deemed it necessary, so pay it.’ A payer is not going to listen to or consider this type of verbiage when overturning a denial on appeal,” Horne says.

Turn to Technology

One of the best ways you can easily access information about the visit or original claim is to have a centrally stored record with all of the details about care necessity and delivery.

“It is extremely important to use a technology database or software to track all documents that pertain to a certain claim,” Horne says. “This technology should also tell you when an appeal is received and its due date so that the software could be used to select the appeal that is due next rather than in the order in which they were received.”

Nail Your First Appeal

Lastly, the appeals process is a very frustrating one, for example, according to the AHA, hospitals report that nearly three-fourths of appeals are sitting in the appeals process. This makes it even more important to have your first appeal letter contain sufficient documentation to overturn a claim.

Becoming a student of the process and preventing repeat mistakes is critical, because unresolved claims can have a detrimental impact on a healthcare provider’s bottom line. While there are some issues involving denials that were at no fault from the healthcare provider and could not have been prevented, there also are plenty of mistakes that can be avoided in the first place. If you move forward with these tips in mind – and practice basic preparedness and diligence – you’ll be able to right a substandard or lackadaisical approach to appeals and start collecting more revenue for your hospital.