How to Appeal a Claim Denial

All too often, when faced with a denied insurance claim, many physicians accept the decision and write it off as a loss.

This is a mistake, says Donna White, owner of Legacy Consulting Services in Montgomery, AL. “I find that many practices are not that familiar with the appeals process,” she says. For example, they may not realize how often denials are caused by easily fixed paperwork errors and that even medically based denials are frequently overturned on appeal. White estimates her clients’ appeal success rate is about 70%: “They very often can get paid as long as they follow the process.”

However, that may be easier said than done. Consider following these tips to navigate the appeals process.

Be Timely
Every payer puts its own time limit on when claims can be filed. Some are as long as 1 year, whereas others are as short as 90 days. Your staff members must be cognizant of these deadlines and prioritize the ones with shorter filing deadlines. It can also get tricky when filing secondary insurance claims. If the secondary insurer has a shorter time window than the primary insurer, then the secondary claim may be unfairly denied.

“Sometimes, we send our hardcopy claims by certified mail, return receipt requested, especially for larger dollar claims, to prove we sent it in a timely fashion,” White says. Such documentary proof can be vital during appeals.

Remain Organized
Keep your appeal argument tightly focused, and do not submit boxes of random, disorganized notes and paperwork. If the payer requires a specific appeal format, then follow it precisely. If handwritten charts are illegible, then have them typed. In addition, be prepared for a second or third appeal if the first is denied.

Oftentimes, medical necessity questions are not even considered until the second appeal.

Stay Current
Staff turnover is common in the health care industry. For new employees with limited reimbursement experience, it can help to hold training programs or create documents that outline strategies for handling appeals. These guides should be regularly updated, because payer rules are in constant flux.

“Blue Cross has town hall meetings all year long in many states,” says White. “Attend those meetings. Go to your payers’ websites and sign up for their provider bulletins. You have to be informed. These tools should be discussed in regular staff meetings to help prevent future denials.”