6 Tips for Successful Third-Party Payer Appeals

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6 Tips for Successful Third-Party Payer Appeals

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third-party payer appeals

When even the slightest mistake on a claim form can lead to a denial or reduced reimbursement, you need to be on your toes. The good news is with some leg work third-party payer appeals can get you paid more of what you are due.

While third-party payer appeals are a time-consuming complex process, they’re worth your efforts to get paid for the services you provided when done right, they are worth your efforts. Unfortunately, they can sometimes feel like an uphill battle.

With so many reasons for your claims to be denied, you need proven strategies to fight back. Here are several expert tips to help you reduce and recover more of your denials.

#1: Prevent Denial Triggers That Prompt Third-Party Payer Appeals

You can better prepare yourself to ward off claim denials when you know what triggers them in the first place. There are several reasons why third-party payers deny payment on your claims. Some of the more common reasons for you to be on the lookout for include:

  • Claims with incomplete or inaccurate information. Whether you misspell a patient’s name or neglect to include the patient identifier information, double checking that forms are filled out accurately and completely goes a long way in preventing denials.
  • Not obtaining pre-certification or prior authorization for a claim. Except in the case of an emergency, many radiology and surgical procedures require pre-authorization — and will be declined if not obtained. Submitting a service for pre-authorization also prevents you from providing a service that an insurance company simply won’t cover.
  • Claims that contain missing or incorrect codes. ICD-10-CM and CPT codes are updated annually and at periodical intervals, so it’s imperative that your billing staff stay abreast of any changes. Claims with incorrect CPT codes and/or modifiers or with mismatched ICD codes can easily get denied.
  • Claims processed for procedures not deemed medically necessary. Insurance companies aim to cover services they deem reasonable, necessary, safe, and not experimental. Payers vary on what services fall within these limits. Clinical documentation that supports medical necessity improves your chances of getting reimbursed for a claim.

#2: Track Third Party Payer Appeals Trends

While denials are part of the insurance game, paying attention to trends will shed light onto where your practice can improve. For example, if a good number of your denials are due to lack of pre-authorization, you might need better processes put in place to pre-cert your services.

Likewise, if you’re receiving a lot of denials for incorrect coding, it might be time to get some training in procedure coding to avoid future errors. When handling third-party payer denials, here’s how to expedite the process:

  • Respond to third-party payer denials or requests for further documentation promptly
  • Establish proper documentation strategies for denials to ensure better tracking of anticipated reimbursements
  • Follow all the instructions from the third-party payer; don’t just resubmit claims

#3. Keep Well-Detailed Documentation

Getting paid for claims requires being proactive with your documentation. Don’t wait until you’re faced with a denial. Practice good recordkeeping and detailed documentation during all phases of your patient encounters.

This will greatly benefit you should you need to file an appeal. For example, sometimes a payer will request further patient medical information to process the claim. Some of these records include:

  • Radiology and pathology reports
  • Surgical records
  • Referrals
  • Lab test results
  • Patient examination notes
  • Specialist consultation records

Your ability to access and produce these accurate and well-documented records is critical to getting paid.

#4. Document All Third-Party Payer Appeal Correspondences

When handling third-party payer appeals, you should keep detailed notes from all your emails, letters, and phone conversations. Be sure to include:

  • The date and time of your conversation
  • The representative’s name
  • Any follow-up action required by you or the payer.

#5. Prepare a Third-Party Payer Appeals Letter

To appeal a third-party payer’s denial, a written letter serves as a comprehensive communication tool. This is when all your detailed documentation comes together!

While the reason for coverage denial will vary by patient, the contents of a third-party payer appeal letter should follow a similar format. When you prepare a third-party appeal letter you should:

  • Communicate clearly and concisely
  • Be polite in your communications, and avoid being combative
  • Reiterate the payer’s reason for denial in your letter
  • Include the reason for medical necessity, backed up with clinical symptoms that resulted in the claim
  • Back up your reasons with proper ICD and CPT codes
  • Be specific with dates and clinical findings when you reference past patient visits
  • Outline how covering the current service is more cost-effective than letting the patient’s medical condition progress or worsen
  • Remind the payer that you are filing the notice within the required time frame

Time saver: Speed up your time writing appeals letters for scratch. Download for free two appeals letter templates for two of the most common modifier denials: modifier 25 and 59.

#6. Escalate Underpayments, Refund Requests with Litigation

Third-party payer appeals shouldn’t feel like a losing battle. But there’s more to appeals than overturning denials. Third-party payers will sometimes attempt to underpay you for the services you provide or claim you’ve been overpaid and request a refund.

Unfortunately, sometimes you need to use arbitration and litigation to get more of the money you are due.

You need resources! Healthcare attorney, John T Synowicki, JD, offers many practical, step-by-step third-party-payer appeals strategies in his online training session.

As a specialist in payer dispute issues, John knows how to get third-party payers to cough up the cash, and he’s going to tell you how.

Recommended Appeals Prevention Online Medical Training