No one likes to get a claim denial from Medicare. You have a few options in this situation: Either appeal the claim or eat the cost of the denied service.
In most cases, filing Medicare appeals will allow you to boost the odds of getting paid, but you must avoid these five common pitfalls.
1. Counting on the Original Billing Company to Fix Errors
If you use an outsourced billing organization to submit your Medicare claims, it may not be a good idea to count on them to identify and fix any errors during the appeal process. If they made the errors in the first place, it could be a good idea for someone in your practice to analyze the original claim, find out what caused the denial, and process the appeal.
If you do find issues with claims that your billing company submitted, let them know right away. For instance, if the billing firm forgot to add medical records to claims with unlisted codes on them, Medicare usually won’t reimburse the claim. To catch this before the problem spreads, let the billing firm know about the issue you identified and remind them to always send procedure notes with unlisted claims in the future. Let them know you’re appealing the denial and submitting the records so they understand that their mistake created extra work and they understand the gravity of the oversight.
2. Appealing on Principle Alone
If your practice has a policy to appeal every denied claim, it’s time to rethink that protocol. Appeals are time-consuming and costly, and in some cases, Medicare was correct to deny claims. No practice has a 100 percent success rate in accurate claim submissions, and it’s possible that your services simply did not meet Medicare’s payment criteria.
You should pursue the appeals process when it’s cost-effective to do so and you believe your odds of success are high, but it’s important to evaluate every claim before appealing.
3. Missing Filing Deadlines
Medicare maintains very strict filing deadlines for each level of appeal, but for the initial level, you typically have 120 days from the denial date to request an appeal. If you miss that date, you may be able to ask for an extension, but you’ll have to explain why you missed the deadline in the first place, adding another layer of complexity to the process.
To avoid issues, don’t hesitate to request an appeal to your denied claims. There’s no reason to sit on your denials—prioritize appeals and ensure you get them in well before the deadline.
4. Failing to Maintain Records During the Appeal Process
As you go through the appeals process, you must document the name of every representative you talk to, and keep a log of everything they told you. In your appeal record, write down why your claim was denied, how you followed up on the denial, the names of everyone you talked to, what they said, and which dates you moved through every step of the appeal.
If you end up having to take your appeal to the next level, you’ll be armed with detailed information about what you’ve already accomplished, helping speed the process. In addition, if another party needs to get involved—like an attorney—you’ll be able to give them a thorough record of what you’ve done.
5. Failing to Fix Issues Going Forward
Sometimes you have to appeal because you’ve filed a claim that’s in a coverage gray area—such as a frequency denial. But in other instances, you may need to appeal because something wrong happened during the initial claims process on your end.
Fixing the issue across the board can help prevent future denials and the accompanying appeals, so be sure to fix any problems you see in your coding, billing or claims processes, and train your staff on how to file clean claims, with examples from past denials. This will help you reduce your denials and save time since you won’t have to appeal as many claims going forward.
You can bring in significant income if you master the appeals process. Get step-by-step strategies from nationally-recognized expert Sean M. Weiss, CHC, CMCO, CEMA during his 60-minute online training, “Boost Your Medicare Appeal Results, Get More Claims Paid Fast.” Register today!
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