How to appeal insurance denials
Step 1: Appeal Timely
Industry experts estimate that more than 70% of denials can be overturned. Despite that encouraging statistic, the greatest challenge most medical billing professionals face is timely appeal submission. Medicare appeals must be filed within 120 days of the claim decision; most commercial insurers require appeals within 180 days from the denial. Due to the sheer volume of claims most offices file, deadlines often pass before action is taken. If the appeal is filed late, the likelihood of success is significantly reduced. In order to meet appeal deadlines consistently, medical offices must have an appeal letter database where letters can be selected and quickly customized for any type of appeal. Attempting to provide a detailed Level appeal is often a stumbling block to timely appeal submission.
Step 2: Appeal Twice
Most denials require two appeals for two reasons: first, insurance carriers do not always provide credentialed professionals for the initial review and second, insurance carriers often provide details in the Level I appeal response which may require further discussion. Level I appeal responses should be scrutinized for legal and contractual compliance. Some of the potential questions you should ask include:
- Has the insurer provided the internal rules, guidelines or review criteria applicable to the denial? If not, is the carrier in compliance with potentially applicable denial disclosure laws?
- If provided, does the internal rules, guidelines or review criteria cited by the insurance carrier actually apply to the treatment in question? Do the internal rules, guidelines or review criteria conflict with your internal quality care standards?
- Has the insurer provided review by a credentialed professional familiar with the type of treatment and has that credentialed reviewer suggested appropriate alternative care which has equal likelihood of efficacy?
- If the appeal involves a question of medical coding, has the insurer provided review by licensed coder familiar with the type of treatment?
If the appeal involves a managed care contract or fee schedule, is the most current contract or fee schedule being utilized?
Level II appeals should address all details regarding the justification for payment and should also address the shortcoming or inapplicability of the information cited in the Level I appeal response. Finally, citing applicable regulatory information in appeal letters assures you that the appeal will also be considered from a compliance standpoint.
