DRG Coding Advisor
Attitude, perseverance keys to the appeals route
Place the burden on the MCO
(Editor’s note: The following guest article was prepared by Appeal Solutions, a Texas consulting firm specializing in medical reimbursement and appeals management issues.)
"Attitude is more important than facts." This quote is from noted psychiatrist Karl Menninger, who understood the vast importance about attacking a difficult situation with a strong mindset.
In appealing denied insurance claims, you need to have the mindset that it is the insurance carrier’s burden to prove that the claim was not processed correctly and that any ambiguities in the coverage terms were construed in the insured’s favor. A strong mindset will also give you the perseverance necessary to continue to appeal a claim the insurer strongly defends. Attitude is more important than facts, because the right attitude will help you persuade the insurance carrier to look at the facts differently.
Many claims are overturned after a single appeal letter. If that’s not the case, you want to persist with filing appeals until you get a satisfactory answer. When you do not receive an adequate response to your appeal from the appeals committee, it is imperative that you continue to appeal. Persistence is often the key to overturning a denied claim. Many carriers overturn as many denials on the second and third appeals as on the first appeal. It is crucial to keep the appeal active, even after the initial denial. In fact, statistics released from major insurance carriers indicate that about 25% of appeals are overturned on the first appeal and another 25% are overturned on the second appeal.
If you believe payment is indicated by the policy terms, continue to appeal the claim. See below for information on keeping your appeal alive.
Don’t settle for denial upheld’
It’s not unusual to find that your carefully researched and strongly worded appeal is not being reviewed adequately by the claims department. In such instances, you can redirect your appeal to someone in a better position to review and respond to the information you have cited. Consider sending your appeal to one of the following:
• Carrier’s legal counsel. If you have cited regulatory information, you can request a review and written response from the legal department.
• Carrier’s president. If your appeal involves a possible breach of claim processing procedures, ask the president or other senior management official to respond.
• Department of Labor. If the insurance is self-funded, file a complaint with the U.S. Department of Labor. Send a copy of the complaint to the insurer.
• Employer. The employer will have an appeals committee if the group is self-insured.
• State department of insurance. File a formal complaint with your state’s department of insurance if you are unable to get a satisfactory response. Send a copy of the complaint to the insurer.
• State medical association. Many medical associations now have a complaint review process and will assist you with resolving denied insurance claims.
As you work your way up the appeals food chain you must make sure your request for intervention is clear and convincing. Letters to an insurance company president or legal counsel, for instance, should be specific as to where the appeal reviewer failed in the review of your claim.
Some common complaints providers have about the claims review process include:
- The appeal reviewer did not fully review a certain portion of the medical records. State which portions you wish to have reviewed and addressed.
- The appeal reviewer was not trained in your medical specialty.
- The appeal reviewer did not gather sufficient proof to justify the denial. Even though the carrier may have an official position on the treatment course, the reviewer must still assess the appropriateness of this particular treatment for this particular patient.
- Case or statutory law was cited in your initial appeal letter, but the reviewer failed to cite any case or statutory law in the carrier’s favor, or offer a different interpretation of the law you quoted.
Tip: If the reviewer essentially ignored the law your letter cited, an additional review is justified.
When you follow up on the status of these letters, your call will likely be screened by the management party’s assistant. Clearly state that the information you want to discuss is highly technical and you need to speak directly with Mr. President or Mr. Legal Counsel. If the company president fails to respond within a reasonable time, direct the letter to the legal counsel and vice versa.
If you are seeking reconsideration on a number of claims dealing with the same issue, seek a face-to-face meeting with top management officials. Ask that the meeting take place in your office. You can then assemble the many parties affected by the denials including professional staff, billers, and even patients. Follow up any phone and face-to-face conversations with a letter detailing what issues were resolved and your understanding of how future similar claims will be processed. If there are still unresolved details, you will need to restate your position on these issues and indicate that you would like a written response regarding the unresolved issues.
Bottom line: Tenacity may be your biggest asset when appealing claim denials. Do not give up until you are satisfied with the answer you receive.
You can contact Appeals Solutions at 1565 W. Main Street #208, Lewisville, TX 75067. Telephone: (888) 399-4925. Fax: (972) 420-7880. E-mail: [email protected].
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