Appeals can feel so overwhelming that you wish you had superpowers to help you prevail in your struggles with payers. Wouldn’t it be great if you had The Hulk’s ability to crush bureaucratic obstacles, Wonder Woman’s Lasso of Truth to cut through all the doublespeak, or Superman’s ‘faster than a speeding bullet’ alacrity to expedite the whole process?
But you don’t need all those superpowers to win an appeal. Let Batman be your role model.
Batman has no superpowers or magic devices. He’s just an ordinary guy who’s learned a lot and has a well-equipped, trusty utility belt. Prevailing in an appeal is simply a matter of learning some techniques, preparing yourself, and gathering a few tools for your own utility belt.
“Everything’s impossible until somebody does it.” —Batman
Billers, coders, and practice administrators: I want to empower you to do just that. During my career, I’ve worked both for physician practices and for a major insurer. Having experienced both sides of the appeals process, I’ve gathered the tools that are most effective for winning an appeal. So get out your utility belt and get ready to equip yourself with these trusty tools for success.
A signed authorization from every patient that gives your practice permission to represent them in an appeal—just in case
At intake, have patient sign an authorization so that you can represent them in the appeals process if necessary. A signed authorization is a counter-argument for one reason some reps give for not being able to review the appeal—that “because of consumer protection regs,” they can’t share data with you. That’s bunk, and a signed authorization form on file can help you move past that particular kind of stonewalling.
You can use forms available from Medicare or your state as templates for your form, customize the form for your practice, and pass it by your attorney to review before distributing it at intake.
Details of your practice’s contract with the payer
The payer contract holds the answer to many questions. Do you know where it is? Are you confident you have the most recent contract on file? (Payers change their rules often.)
If it feels like too much of a drag to plough through the contract, remember: The more time on spend preparing the appeal at the front end, the less time you spend fighting with the payer later.
The contract describes the payer’s appeals process. No two payers handle appeals the same way, so you shouldn’t use a cookie-cutter approach to appeals. Tailor each appeal to fit the payer’s requirements. If it feels
As much understanding as you can gather about how your payer’s processes work
Your contract with the payer is just one way of understanding how claims processing and appeals work there. To make shrewd decisions, you need to understand how payers operate, who’s reviewing what at which times, and how each person you may encounter can and can’t help you. As much as you can learn about particular payers (see Tool #4) is helpful. Getting to know payer reps through professional associations such as the American Academy of Professional Coders or the American Health Information Management Association is an excellent way to learn how the other half works.
Tip: Understand the limitations of your payer’s customer service representatives. CSRs aren’t coders and billers, and most are kids still in college who are reading scripts. If they tell you they can’t answer a question and are “escalating” it for you, they’re typically passing you to someone else in the CSR department with 10 additional hours of training. They aren’t the folks processing your claims, and at many payers, CSRs aren’t even working in the same building as claims processors. The information a CSR can provide is usually limited to claim receipt and whether it’s in adjudication.
How Appeals Work: Payer Perspective
During claims adjudication, claims generally pass through a computer with an optical reader program. If the computer kicks out a claim, it typically goes to human readers who aren’t coders. If the humans can’t resolve the problem, they suspend the claim.
Every appeals process at every payer is different, but generally there are three levels:
During the first level of internal appeal, reviewers are usually high-school educated folks without much RCM or medical experience.
At the second level of internal appeal, the claim will hit coders, auditors, and nurses. There may be one or two levels of internal appeal, depending on the plan type and design. If specialty knowledge is required to review the appeal at this stage, you have the right to ask for the reviewer’s medical qualifications. Ask about their education level, and ask whether the review was condition- or case-specific.
The third level of appeal is the only step that must occur on externally, with the reviewer being someone outside the health plan. Hence the term “external review.”
Good working relationships with your counterparts on the payer side
Sometimes it can be so frustrating to work on denials and appeals that it’s tempting to dehumanize the folks working on the other side. Remember that many are folks similar to folks who work in your office, and many have worked in physicians’ offices themselves.
If you get to know payer reps as people, the whole process will become less gummed up for you. Make small talk and develop genuine personal relationships with your counterparts on the payer side. What begins as small talk can end up as substantive discussions that help you understand what happens to claims upon submission at that payer, who the medical reviewers are, and how you can contact reviewers. You may end up with direct line numbers and other tools that make your work easier for you.
A well-written appeal letter
First the basics: you’d be surprised at how many appeal letters fail to mention what is being appealed! An appeal reviewer who is working under a quota will not spend time tracking down a claim number that you have forgotten to mention.
Customize the body of your appeal letter to succinctly and thoroughly describe what happened and why you think it should be covered. Resist the urge to dash off a canned form letter, even if the payer is sending you its own canned form letters. A well-written, well-supported appeal letter gives you a better shot at obtaining your goal.
Tip: Short factual statements are more likely to win appeals than letters that are long, full of emotion, or digress into commentary that isn’t relevant to the claim. Your reimbursement team may feel frustrated, but the letter to stick to facts and logic.
Citations for federal regulations
There’s a lot not to like about the Affordable Care Act, but it does have an upside. The ACA makes it very clear that providers have appeal rights, and payers are seeing more appeals that cite compliance with the statute as a reason for considering the appeal. If you cite the ACA in your appeals letter, you will grab your reader’s attention. Citing the reg will likely get your appeal beyond the person without knowledge working on first-level appeals and into a more qualified reviewer’s hands.
Another upside to citing a federal regulation: You force the payer to join you in a logical dialogue about nuts and bolts policies—not feelings or emotions. If the payer disagrees with you, you can ask, “Well, then, what reg do you follow and why?” At the end of the day, the only thing that may get some payer reps truly engaged is citing the law.
Eyes Open: The cite is 45 CFR § 147.136 of the ACA statute, which describes provider rights to external review during an appeal. It outlines the process for bringing in a neutral Independent Review Organization (IRO) to resolve the issue. An IRO’s decision is binding, and you can’t appeal the claim after that.
Tip: When appropriate, use the phrase “In order to seek a transparent process…” in the body of your appeal letter. This language signals to knowledgeable reviewers that you know ACA compliance inside and out and that, because of that, you’re not going away until you reach a satisfactory resolution.
Citations for state regulations
In addition to the ACA, make sure you’re up on your state’s external review regulations. Some states have their own statutes that could support your appeal.
When I was working for a major insurer, I often saw appeals with no supporting documentation except for the provider essentially saying “pay me.”
Appeals are time-consuming, so if that’s all you’re going to do, you might as well not bother to appeal. Your appeal packet should include:
- Method of tracking for the payer (patient ID, claim form, etc.)
- Payer’s appeal form
- Supporting documentation including:
- Medical record documentation
- Documentation from:
- Peer-reviewed journals
- Pub 100 references
- CPT Assistant
- Payer’s policy
- ICD-10 specific policies
- Letter of appeal
- Supporting documentation including:
Tip: A common denial reason from payers is that the treatment is experimental or investigational. To counter, pull and append data from other states that show other payers are paying.
“I have one power. I never give up.” —Batman
Careful record keeping
Develop an excellent tracking and tickler file system in which you document every single time you talk to a payer representative during an appeal. Record the name of the person you talked to, the date and time you talked, and a brief synopsis of each conversation.
Side benefit: Sometimes physician owners become impatient during a high-stakes appeal—so impatient that they want to contact the payers themselves. It’s up to RCM staff to keep physician owners from becoming their own worst enemies and adding to the already substantive chaos of an appeal. Clear records of your contacts with payers help you assure a concerned provider that there is a process and you are on the case.
Sometimes payer reps “lose” letters and supporting documentation as a stalling tactic. (Oopsie!) If you suspect this is the case, send your appeals packages in certified mail.
Prospective appeals are underutilized, but they offer incredible benefits, especially as value-based reimbursement trends continue to put the squeeze on clinical appeals. It’s generally easier to appeal pre-treatment as opposed to post-treatment. Time frames are more rigid than for post-treatment reviews. (Between 24 hours and 15 days in the norm.) So you plough through the internal phase more quickly and get to the external review phase more quickly.
Pre-treatment reviews also require peer-to-peer conversation, so it’s a good opportunity for your ophthalmologist to make the case directly to a medical reviewer—doctor to doctor.
Tip: Google your state’s division of insurance to learn the pre-treatment timelines payers must follow.
Timely filing rules that typically apply to claims also apply to appeals. Most payers allow 180 days to file an appeal. Therefore, don’t be late—not even by one day. If you miss the appeal window, legally the payer doesn’t have to take action—so establish the systems and processes you need to hit those deadlines.