Denial Appeals Process in Medical Billing

Your main goal is simple: you get your practice paid. But your goal isn’t a simple undertaking, especially when it comes to appealing denied claims. Reimbursement becomes a messy, convoluted web of tasks made up of multistep to-do items. But that doesn't mean your claims are unrecoverable, right?

Denial Causes

 Approximately 49.7% of denied claims are caused by front-end problems, per the Change Healthcare 2020 Denials Index. Change Healthcare found these front-end issues as the largest ones: 

  • registration/eligibility issues
  • prior authorization/precertification
  • service not covered. 

 Though most denials come from front-end problems, Change Healthcare found these additional reasons that denials occur:

  •  medical documentation requests
  • medical necessity
  • medical coding
  • avoidable care
  • missing or invalid claim data
  • untimely filing

The aforementioned list isn’t an exhaustive list; however, it shows a variety of denial causes you probably have in your denied claims list right now. Some of these issues are unrecoverable, yet avoidable. To learn more information about how to avoid denials,  read our past article linked here. 

Fortunately, many denials are recoverable, but the process tends to be a lot of work. Below, we’ll dive into the appeals process and how Rivet’s denials management tools will change the way you work appeals. 

The 4 basic steps of the appeals process 

1. Establish appeal legitimacy. 

 We’ve talked about possible denial reasons, but it’s likely your practice doesn’t have the resources or time to file every appeal. Furthermore, some denials are hard denials, meaning the claim cannot be recovered and you will not receive any payment from the insurance company. You’ll need to make sure a denial is worth your time and effort before jumping in. 

Rivet’s Denials Management software helps you organize your claims data in an easy-to-use format. You’ll see line item claim details, adjustment codes and diagnosis codes all in one place so you can easily solve problems. 

2. Gather needed appeal information and documentation. 

 Once you’ve decided to appeal a denied claim, you’ll need to gather anything that could be useful in obtaining payment, such as the following: 

  •  A letter of appeal or explanation: This is a cover letter or summary of sorts that explains to the payer why you’re appealing the claim and how your documentation supports those reasons. This is often the most tedious part of the process. 
  • Supporting documentation: This includes any progress notes, patient labs or other formal medical record documentation from the health insurance company or medical committees that support your claim. Think of it as your evidence in a trial—it’s got to convince the jury of your case. 
  • Insurance EOB or claim number: This seems like a no brainer, but you’ll need it. Oftentimes, an appeal gets lost or processed as a duplicate because the insurance company can’t connect the appeal to the original claim. (Remember, insurance companies receive thousands of claims every day, so they aren’t going to make the connection for you.)
  • Follow the specific insurance’s appeals process: Almost all insurance companies have a specific way they’ll accept an appeal. It’s not worth your time working an appeal if no one even looks at it. They might have a specific form you’ll need to fill out.  

 With Denials Management workflow tools, you can automate forms and data fields in Rivet so you can reduce error and manual data entry. Keep continuous record of instructions, payer policies and payer contact info by payer and denial type. 

3. Send the appeal to the payer. 

 You’ll most likely get the mailing and any electronic sending addresses from the company’s website when you get your insurance-specific forms. You may see it on the Explanation of Benefits (EOB), but be sure that is actually the correct address for sending appeal letters. You don’t want to do all the necessary paperwork to have nothing come of it.  

 Save useful information in Rivet for easy reference when working an appeal with the same payer. 

4. Receive some amount payment or another claim denial.  

Now that you’ve received an answer to your appeal, you can do one of two things: 

  • (1) Do a happy dance because you got paid what you deserved!
  • (2) Take your appeal to the next level because you didn’t get paid what you deserve. 

 The following are the three different levels of appeal: 

  •  Initial appeal/claims reconsideration. You’re asking for a reconsideration of the claim. This is your first appeal attempt and what is described above. If you are unsatisfied with how the claim was processed, you can escalate the appeal to the next level... 
  • Secondary appeal. This is a longer and more intense follow up process. The insurance company may send the claim to an appeals specialist instead of a lower-level claims processor. If you are unsatisfied with how the claim was processed, you can escalate the appeal…
  • Provider relations. Each insurance provider has a provider relations rep who specializes in communication between healthcare providers and the insurance company. If all other appeal attempts fail, you can reach out to the provider relations rep to see if you can get your claim paid.  

If your claim status requires further action, you may report the health insurance company to your state medical association. They will help you file a formal complaint and possibly launch an investigation into the insurance provider’s claims processing. 

Claim Deadlines 

 If you’ve worked in denials management before, you know that filing deadlines need to be tracked so that you stay on top of denied claims before you run out of time. 

 With Rivet, you can automate your team member’s task lists, track all of your denials to completion and stay on top of deadlines. 

 Want to know more about our Denials Management or other products? Visit our info page on our denials management software or schedule a demo

Download  Denials info page

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