How To Appeal Denied Claims
- Volume 25 - Issue 8 - August 2012
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Keys To Documentation That Can Bolster Your Claims
Your best defense in an appeal is your chart note. This should clearly indicate the patient’s chief complaint, your examination, services performed and eventual decision-making. This will bolster the validity and medical necessity of any diagnostic tests or procedures/services you performed. Chart notes are especially important in evaluation and management services as the office level selected needs to meet specific criteria.
Briefly, an evaluation and management service requires documentation of history examination and decision making. There are different levels within each category such as problem focused, expanded problem focused, detailed and comprehensive examinations. The diagnosis alone does not determine which of these categories you select. Rather, it is the documentation in your chart that determined the category. If the patient presents with a very complicated problem but the chart note is only a few lines long, that service may not qualify for a higher level code. If you perform procedures, make sure there is a procedure note that validates the billed codes.
When selecting a procedure code, be careful not to unbundle. If there is a code that represents the various components that you performed, you should bill that single code. That said, make sure you bill for all the services you rendered. If you are unclear as to what may be considered as included in another procedure, this is another source of education that the office should investigate.
When performing diagnostic studies, you have to document medical necessity. Simply doing “rule-out” type tests may not meet payment criteria and accordingly meet with denial. There must be documentation of a written report indicating a properly performed examination and a proper interpretation.
Should the practice review paid claims or just the denied ones? Although it is obvious that denied claims need review and appeal, do not disregard those claims that receive proper payment. Remember that audits occur on paid claims. You should spot check even the paid claims periodically to make sure you are billing properly as sloppy billing practices may still result in both payments (eventually possible audits) and claim denials. This is a way to protect yourself from audits, which can be very disruptive and costly to the office.
In addition, if there are problems with an insurance carrier to the degree that getting authorizations and getting claims paid correctly (and promptly) is difficult, and if the carrier does not seem to be willing to work with you to solve problems, then one consideration is simply not to provide services for that insurance company. You are not obligated to provide services to all patients and all insurance carriers.
If you elect to treat a certain carrier’s patients, then you must follow the company’s rules as far as claims processing, appeals and fees. Keep in mind that some carriers do contract out services such as diagnostic studies or durable medial equipment. Therefore, appealing these services as a non-contracted provider of those services may be a waste of time. Overall, if providing services to a company’s patients is too onerous, then it may not be worth it to deal with that insurance company.
Dr. Poggio is a California Podiatric Medicine Association Liaison to Palmetto GBA J1 MAC and a medical consultant to several national health insurance and review organizations. He is a member of the American College of Podiatric Medical Reviewers and is board certified by the American Board of Podiatric Orthopedics and Primary Podiatric Medicine.