If your medical insurance appeal letters are highly successful, then you’re one of the lucky few. The reality is that most practices see their appeal letters get tossed out, leaving their hopes of overturning denials dashed. One reason many appeals are rejected is because practices make mistakes on them.
Check out three elements that many appeal letters are missing so you can avoid making the same mistakes.
- A Reason for the Appeal
Your appeal letters can’t simply state that you’d like to appeal a denial. You have to explain why you’re appealing. Right near the beginning of the letter you’ll want to tell the payer why you believe they denied your claim incorrectly. Common reasons for appealing include:
- The payer’s policy says it will consider a service medically necessary for the condition your patient has, but the payer denied it anyway
- The payer said you didn’t meet the filing deadline, but you have proof that you did
- The payer said your patient didn’t have conservative treatments before getting surgery, but you have documentation indicating that the patient did
No matter what the reason is, make sure you clearly and succinctly explain why your payer should have paid your claim right near the beginning of your appeal letters.
- Documentation
If you’re trying to convince an insurer that they should have paid your claim, you should include any documentation that supports that assertion. This includes:
- Clinical notes
- An operative report
- Procedural documentation
- The payer’s own local coverage determination
- CPT or ICD-10-CM guidelines
- Provider dictation transcripts
- Any other records that support the fact that the payer should have reimbursed your claim.
Submit the documentation along with your appeal letters to support your assertions in the letter.
- Adherence to Deadlines
If you don’t meet the appeal deadline, you won’t have a chance of success, no matter how thorough your appeal letters are. For Medicare Part B, the deadline to appeal is typically 120 days from the date you receive the initial denial. But when it comes to Medicare Advantage, the appeal date range drops to just 60 days.
Private payers typically have their own appeal deadlines, so always check with your insurer so you don’t miss an important date.
| Make sure every last appeal you handle is approved and paid with help from expert Christine Hall, CHC, CPC. During her 60-minute online training, Proven Appeal Tactics to Get More of Your Denials Overturned and Paid, she’ll walk you through the steps you must follow if you want to collect. Register today! |