Getting dropped by any of your payors is a nightmare, especially if it causes you to lose patients because you’re now out-of-network with their insurance. The first step toward getting reinstated with any payor is to write an appeal letter asking for reconsideration.
But this letter must be carefully crafted in order to help you avoid it getting tossed out and dashing your chances of reinstatement. Make even a simple mistake and the insurance company can disregard your appeal, costing your practice thousands in lost patients.
To give your payor appeal letter the best chances of being read and accepted, avoid these mistakes that can cost you the appeal:
Mistake 1: Misspellings and Bad Grammar
Your aim is to appear exceptionally professional and convince the insurance company that they made a mistake in terminating your contract. Misspelling people’s names or common words, or incorrectly using punctuation marks, can give off the impression that you didn’t take enough time and care with your letter to fully proofread it.
Double-check the spellings of the names of any directors or managers, as well as anyone at the insurance company to whom you’re addressing the letter. Scour your files and the company’s website for this information or call the payor to confirm if you can’t find the spellings on your own.
If you don’t trust your own grammatical skills, have your letter checked over by someone you trust. And, even if you are a grammar whiz, it’s a good idea to have your work looked at by someone else in case any errors snuck by you.
Don’t send this letter out without having at least one other person proofread it. The more sets of eyes you can get on it, the more likely you are to catch issues that may get your letter tossed out.
Mistake 2: Not Getting Proof
Things happen to mailed letters, especially now when it seems to take a lifetime for a package to get from one location to the next. Sending a letter as important as your payor appeal letter without some kind of proof is a huge mistake that could cost you your reinstatement.
For letters going out via traditional mail, consider paying the extra for certified mail or send them with a delivery receipt. These safeguards allow you to double-check that your letter was received and, if something goes amiss, you can send another out prior to any crucial deadline passing.
If you’re sending your letter via email – even if you’re just sending a copy of the same document you’ve put in the mailbox – attach both delivery confirmation and a read receipt. This will notify you when the email is delivered to its recipient’s email box and again when the person opens it.
Mistake 3: Being Threatening
When you receive that letter stating you’ve been dropped from a payor network, it’s easy to get angry and defensive. After all, your practice runs the risk of losing lots of money and your patients may all have to find a new provider! But don’t let this anger come out in your appeal letter.
It’s essential that you take a step back in your letter and not include any threatening or otherwise confrontational language. Instead, be sure your entire letter is calm, collected, and professional.
If you really cannot push aside the angry words, open a blank document on your computer or sit down with a pen and paper and write them all out before starting your official appeal letter. You’ll feel better after this exercise and be in a better place mentally to include only important facts and figures when writing to the payor.
Mistake 4: Rushing Things
Your appeal letter must be thorough, giving all the information and evidence the payor needs to (hopefully) reverse their termination. Don’t rush through your points of evidence and assume that they’ll look through their records.
Instead, take all the time and space you need to cover the ins and outs of each point of evidence without repeating yourself. Again, this is where having the help of a second set of eyes – preferably one that doesn’t know anything about the situation – to read through your letter and ensure you’ve covered everything necessary is important.
It may be helpful to sit down and outline your letter before writing, sketching out all your points and including the evidence and reasoning to back each one up. This way, you’ll sit down with the end in mind and can make better arguments throughout the letter.
Mistake 5: Being Vague
When you cite part of the contract or other documentation, it’s essential that the person reading it can find exactly what you reference if they flip to your attachments. Giving a page number isn’t enough.
Think of including evidence in your appeal letter like citing evidence in a paper for school: Make sure you point the reader directly to the page, section, clause, or line where they can find the information you reference. To really cover your bases, attaching copies of each specific cited section in an appendix puts the information in the packet you send so it’s easily accessible.
Mistake 6: Making Assumptions
Because you work at your practice every day, it’s easy to forget that not everyone knows all the details of the work you do. Even your insurance payors, who do keep crucial demographic information, may not understand the full scope of difficulty being dropped by a plan can create.
Don’t forget to include key details in your appeal letter that could potentially sway the payor’s decision toward reinstating your contract, including:
- Any specific specialties you offer
- The size of your patient roster related to the insurance company
- The impact losing your contract may have on your patient population
- The difficulty your patients may have finding similar quality of care (that takes the insurance) in their surrounding area
Learning, for example, that your practice serves a key subset of patients who couldn’t find your care within 50 miles may cause the payor to reinstate your contract in an effort to provide the best care for their subscribers.
Getting dropped by a payor is never easy, especially if your revenue is closely tied with that company. But you can get those patients back – if you get the appeals process right. For all the step-by-step guidance you need to get your payor appeals right the first time, check out Healthcare Training Leader’s online training session, Get Your Patients Back After Being Dropped by Payor. This expert-led training session gives you the practical advice you need to convince payors to reinstate your contracts. Access this immediately available training today.
If you’re frustrated by payors issuing your practice claim denials, check out Healthcare Training Leader’s online training session, Persuade Payers to Pay Up with Successful Appeals Process. This 60-minute training session gives you the tools you need to successfully undertake a denial appeals process and get your claims approved by more payors. Sign up for this valuable training today.
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