Appeals Best Practices

Providers and medical billers are well-aware that insurance companies will not always pay every claim for the agreed upon rate and for reasons that vary across the board.  When denials or underpayments do occur, it is best practice to first identify if the claims issue needs appealing.  Because appealing is a lengthy and sometimes difficult process, it should be used as one of the final options in basic claims follow-up.  Prior to appealing, the following should be considered:

  • Correct billing:  Commonly, claims denials are the result of data entry errors.  Humans make mistakes and in an industry that relies on minimal human error to be successful, denials based on human error are, unfortunately, not uncommon.  Before appealing a claims denial, determine if the claim was billed cleanly and correctly the first time.  Common data entry denials might include errors in patient insurance information, bundling denials resulting from incorrect modifier usage, or missing information (e.g. referring doctor, accident/injury date, quantity).  Some questions to consider would be: Were the appropriate modifiers used?; Is there a mismatch between the CPT and diagnosis used?; Is any basic patient information missing on the claim?
  • CPT guidelines:  Following CPT guidelines is not always easy to accomplish.  Currently, insurance companies are not required to follow nationally recognized guidelines, such as CMS guidelines, making claims denials all the more difficult to bill cleanly initially and sometimes to appeal.  Even if correct CMS guidelines are followed when initially billing, sometimes insurance companies do not follow these guidelines.  If you are certain that a claim was billed correctly initially, then check the insurance payor’s provider billing or administrative guide.  These guides are usually available online.  If they are not, promptly request one from the carrier.
  • Payor/Provider contract:  Contracting with an insurance company sometimes requires that certain services will be paid at a specific rate and/or may not be billable at all.  Determine that contracted services are being billed and are being billed appropriately.  If contractual procedures are not being followed, then an appeal may not be possible.  It is important for the provider and medical biller to be aware of contractual requirements as well as contracted payor fee schedules to determine that the payor, as well as the provider, are following the requirements set forth by the contract.

When it is determined that an appeal is necessary, then the appeal should be completed promptly and correctly.  The appeals process varies from carrier-to-carrier, so your medical billing company should be well-versed in the appeals processes of common insurance carriers, such as UnitedHealthcare, Aetna, BlueCross and BlueShield (may vary by state), and Medicare (exact process may vary based on the medicare handler).

Most insurance carriers have a standard appeal time frame.  For some, it could be as soon as 45 days after the denial is received.  For others, it could up to a year.  Still for some, there may not even be a timely appeals filing limit.  It truly varies based on the payor.

The exact appeals process may also vary based on the carrier.  As of 2017, numerous insurance carriers, such as UnitedHealthcare and some Medicare handlers, offer the ability to appeal and monitor appeals online.  If an online/electronic means for filing a appeals is available, then the provider or medical biller should absolutely use this method to file an appeal.  However, even in our modern era, some insurance companies still require appeals to be faxed or mailed, making appeal tracking much more difficult, costly, and timely.  If an appeal is filed via fax or mail, your medical biller should follow-up within seven days of filing to ensure that the appeal was received and what the status of the appeal is.  Always maintain a “paper trail,” collecting reference numbers for every call, appeal document tracking numbers, and documenting all conversations with representatives, ensuring that names and employee id’s are documented.  Most insurance companies will have a timeframe for when an appeal will be complete.  The medical biller should continuously follow-up to determine if an appeal is being processed within that given timeframe.  Finally, copies of appeals should be kept for future reference in a secure location, such as a secure server or on a secure, HIPAA compliant online document storage solution.

The above information on appeals best practices are put forth by MedPro Services.  Our team follows these procedures and more, ensuring that our providers are getting paid on time and for what they are owed.  For more information on our A/R recovery and appeals solutions, visit our site here.

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