Cath Lab Digest

   Read the explanation of benefits (EOB) closely as some claims actually need formal appeals while others may simply need correction. This is especially true with Medicare, which may reject the claim outright because of certain errors. One simply needs to correct this type of claim and submit a new corrected claim. If the claim has been adjudicated in some form, then you need to file a formal appeal. Simply submitting a corrected claim (when it should be appealed) will end up with that second claim being processed as a duplicate. Check with each carrier to verify what claims need correction and what claims need an appeal. Some common errors that one could correct may be transposition errors, an incorrect date on the claim form or other technical issues.

How To Write An Appeal And Follow Up

If the error seems to be on the part of the insurance company, write a letter addressing your issues and why you should receive payment for the claim. When writing your appeal letter, be clear and concise. Make sure you address the reason why the company denied your claim. Adding inflammatory comments to the letter serves no purpose. In order to bolster your case, you may submit additional information such as lab tests, diagnostic studies or chart notes/consult letters from other providers. You may submit literature articles if the carrier deems a procedure to be investigational.

   When appealing the claim, look at the EOB carefully and see if there are clues as to why the insurance company denied the claim. When appealing a claim, it is important to ensure you have addressed the issues noted by the insurance carrier. Certain information may be missing and arguing medical necessity would not be of any value because that is not the basis for the denial. Ask for the carrier’s written policy as that may give you clues if in fact the services are covered or if they were incorrectly denied.

   You may also inquire as to what bundling software the company uses if services were bundled together so you may adequately address the bundling issues. Sometimes submitting information from other carriers may help bolster your claim for payment, especially for claims based on relatively new procedures. Other issues to appeal could be incorrect payment and that would be based upon the carrier’s fee schedule that you should have access to as well.

   Once you have written the letter, however, there still needs to be follow-up. It seems all too frequently that every appeal letter process inevitably ends with a phone call in which the insurance company claims it never received the letter. Therefore, the practice needs to develop some sort of system by which you contact the carrier to make sure it has received the appeal. The system should also ensure you find out the expected timeframe for receiving the answer and then following up with a letter or phone call at that time to make sure the carrier has addressed your appeal.

   Many insurance companies have as part of their contract a designated timeframe when one needs to file appeals. If there is no documentation of sending an appeal, you may lose your appeal rights even though you have a valid argument. Sending the appeal letter via registered mail with the return receipt is an excellent way to ensure you sent documentation that the carrier received. This puts the onus on the insurance company to process your appeal. While this may seem time consuming and costly, I would suggest using return receipt mail if the dollar amount of the appeal is high.