The fact of the matter is that claims are not always paid. When a claim is denied, you will gather all of the information relevant to the claim and review it: the claim form, the remittance advice or EOB (explanation of benefits), the remark codes by each claim line explaining why this claim was rejected, the patient’s medical record documentation, and the 3rd-party payer’s fee schedule (if one is provided). If a review of these forms seems to support a payment of the claim—and if that support is well documented—the provider may wish to appeal the claim.
Appeals are often made if:
- A claim is denied for lack of pre-authorization but there were evident reasons why pre-authorization could not be obtained.
- A claim is denied because the payer deems a procedure not medically necessary, yet the physician believes it was medically necessary.
- The third-party payer denies a claim based on a pre-existing condition that the physician does not believe falls under the terms of pre-existing conditions.
- Payment is denied without reason or a lower payment is made without adequate explanation.
- Services are bundled and only one of the bundled codes will be reimbursed.
- No modifiers are used (however, the third-party payer will not directly state this is missing).
The appeal process may vary slightly depending upon the third-party payer, but most of the steps are very similar. The appeal must be made in writing and must state the reason for the appeal (some carriers, like Medicare and Tricare, have forms to be filled out that will act as the written request). Since most carriers have a set time in which an appeal must be made, timeliness is important. There is a window in which appeals must be started they must be dated and make copies of all documents used in appeals process. Attached to this written appeal will be all supporting documents and records.
Following Up on Appeals
The third-party payer will review the appeal. (They usually have internal time limits on their review process, as well—typically 30 days.) They will inform the provider of their decision through a phone call or a letter. If unsatisfied with the decision, the payer may allow for one or more followup “levels” of appeal. At this point, if the payer’s decision is still unsatisfactory, there are steps that can be taken. Some payers will use an objective peer review. The peer review is a group of physicians who can review the claim as well as the supporting documentation and arbitrate the differences between the payer and the provider. They can decide, based on the medical care, the necessity of the procedures performed or services provided, and the payments made, whether the healthcare provider is entitled to a payment or partial payment.
Government insurers, such as Medicare and Tricare, have more prescribed steps in the appeal and review process. These should be followed exactly and within the time limits set forth by their guidelines. For more information on Medicare appeals, visit their website:www.medicare.gov/Pubs/pdf/11525.pdf.
For Tricare appeals information, visit their website: http://www.tricare.mil/Resources/Appeals.aspx.
For more information of appealing denied claims, utilization review, or general healthcare legal questions, please contact us at www.KhatriMedLaw.com or (310) 896-5183 and speak with a healthcare law expert.
Khatri Medical Licensing & Law: "Where medicine and law meet."