Medical insurance claim denials can be devastating to deal with. Not only do they take time and energy — they prevent your practice from collecting revenue for services you’ve already performed. The most common way to tackle a denial is to file an insurance appeal, which can help you reverse those denials.
To ensure that you’ve spent your insurance appeal efforts in the most efficient way, check out five common errors, with tips on how to keep them from occurring at your practice.
Error 1: Appealing Because You Can’t Decide Why the Claim Was Denied
The number one reason practices file an insurance appeal is to show the plan that they denied the claim contrary to their own guidelines. Your job isn’t to persuade the claim reviewer that you were right, it’s showing them where they went wrong. And if you don’t know why your claim was denied, then there’s no way you can create a cohesive appeal that will convince them that they didn’t follow their own guidelines.
Why? Because appealing without understanding why the denial occurred is like throwing spaghetti at the wall and hoping for the best. It’s a waste of your time and the reviewer’s time, and is likely to just annoy them.
How to fix it: Pore over the remittance advice and look up any denial reason codes that you aren’t familiar with, then go back over the insurer’s policy and compare it to your submitted claim to see if they were correct in denying the claim for that reason. If you don’t understand the denial reason codes, reach out to your insurance representative and ask for more information rather than just firing off an appeal without the information you need.
Error 2: Writing Your Insurance Appeal in Clinical Language
When you create your appeal letter, you want to target it to the reviewer. During the first appeal level, that’s almost always a non-clinical person, so you should not be using clinical jargon. You can’t show them where they’re wrong if you’re coming at it from a clinical point of view.
How to fix it: Create your appeal letter using layman’s terms, as if you were writing to someone else in your back office and not to a doctor. If your appeal eventually gets elevated to a medical reviewer, that’s when your provider can step in with clinical language. But during the beginning phases of the appeal, simply show the reviewer their policy that you followed, with the relevant portions of your claim and documentation that show you followed their policy to a T.
Error 3: Using Non-Specific Appeal Letters With Canned Language
The appeals process is meant to be situational and based on very specific details within your claim that match the requirements within the payer policy. Sending an appeal letter that simply states, “This claim shouldn’t have been denied because we met your requirements” won’t be enough to satisfy the reviewer, and is a waste of everyone’s time.
How to fix it: Use your insurance appeal letter template simply as a guide rather than as a final version of your appeal. Plug in details from your claims and the payer’s policies to show why the claim should have been paid, along with dates, excerpts and verbiage from that specific claim that demonstrate why.
Error 4: Shopping Your Appeal Around the Insurance Company
Some practices will send their appeal letter to multiple people throughout the insurance company as a way to boost their odds of overturning the denial. Insurers have an appeals department or appeal contact person for a reason — because that’s who’s designated to handle your appeal. If you send your appeal to others, they will simply forward it to the appeals contact, who will then get multiple copies of it, leading to confusion.
How to fix it: Pinpoint the specific person who handles appeals at your payer organization and send them a well thought-out, comprehensive appeal letter with documentation showing why the claim should have been paid. If they uphold the denial, then you can send it to the next point of contact based on that payer’s appeal preferences.
Error 5: Missing the Insurance Appeal Deadline
Insurers have extremely rigid deadlines about when you’re eligible to appeal your claim and when it’s too late. If you miss a deadline, you have no recourse at all, and must accept the denial as it stands.
How to fix it: Keep a list of every payer’s denial stages, with the deadlines for each. In some cases, the same payer will have different deadlines for different appeal stages. For instance, the level one appeal deadline might be 45 days, while level two might be 30 days. Tracking these timelines will help you meet the deadlines.
Filing appeals can be time-consuming and stressful, so it’s important to do it right the first time. Let expert Tressa Harley help during her online training, Get Your Denied Claims Paid Fast with Proven Appeal Process. Register today!
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