In part 1 of this article, we looked at 4 steps to check your billing and coding on denied claims. Using that information you've checked your coding, your modifiers, your units and your onset dates. What you submitted meets the generally accepted standards and it was denied!? It happens every day.
Most offices don't take the time or have the expertise to appeal denied services. Insurance companies "bank" on the fact that less that half of denied or bundled claims are ever appealed. Don't take those denials – get paid for the services you perform!
#5 - Appeal the decision: Get ready to write!
Determine the basis for your appeal; incorrectly bundled? Medical Necessity? Create an appeal letter that clearly and simply states why this claim should have been paid. Leave your frustration at your office and offer a compelling, fact based, CPT driven reason the claim should be paid.
#6 – Review the rules for appeal
Review the EOB or the on-line provider resources for the insurance company’s appeal process. Take note of the time frame for receipt of the appeal and the time frame under which the insurance company is required to respond.
Some carriers require their own appeal form (Blue Cross/Blue Shield, United Healthcare), while others do not. Keep a copy of the letter/form, documentation you attached, date and address to which the appeal was sent.
#7 – Appeal the decision.
Mail the appeal – you can send it certified if you prefer, but document what, where and when you appealed the carrier’s decision. Be prepared to follow-up if you have not received correspondence or payment regarding your appeal. Follow-up on these pended claims should begin 4-6 weeks after records are submitted.
If your office is experiencing a pattern of records requests, a thorough review of your billing practices and documentation might be in order. For assistance in this and other healthcare related matters, contact us at 888.887.5259.