I nsurance appeals are a necessary evil in every chiropractic office. Understanding how to work with insurance companies to ensure reimbursement is critical to having a zero account balance for every patient. Many doctors and CAs have not been trained properly to draft and send appeals, so confusion about what to do often leads to nothing being done. Take a moment to think of the ballpark figure in dollars that yoifvc written off due to denied claims that simply may have needed to be appealed. It's likely to be a number larger than the one representing the cost of training your collections department CA. Start here to better understand the art of appeals, and then continue to dig deeper with more training until it is an automated process in your practice. There are numerous reasons to appeal a denied claim, including: Won appeals will improve your bottom line. Appeals allow improved communication between insurance companies and providers. Not appealing could make it appear as though you were billing fraudulently. • Sending appeals allows you to defend your services rendered. Begin Here The first step to appeals must begin before starting the appeal—as in when the denial appears in the mail. You must have a process in place for c\ cry step, from opening and processing the mail to the systematic steps taken when posting payments or zero balances to place them into the queue for a follow-up. This type of system allows you to properly organize and manage every operation within the financial department, setting up the course of action required to accurately appeal. When an insurance company denies a claim, step one should always be to determine the reason the claim was not paid. Was it due to an administrative error such as an incorrect ID number or transposed date of birth? Was the sen ice considered "non-covcrcd"? Maybe the insurance company wants proof of medical necessity orfelt the diagnosis didn't make sense with the CPT codes submitted. Whatever the case, you must fully understand why the claim was denied before being able to take appropriate action. Administrative Errors When you discover that the denial is due to an administrative error, simply correct the information within your system and rcsubmit the claim. You may have to mark the claim as "corrected" or use other forms required by your insurance company to rcsubmit claims because you dont want them to be denied again as a duplicate claim. The most important step in rcsubmit- ting for an administrative error is to utilize your "tickler" system to verify if you have been paid within an adequate amount of time. Re-sent claims are often confused or lost in the shuffle on the carrier's end. and your follow-up is imperative to being paid! As with all internal reminders, place a note in your reminder system four to six weeks out to check that this claim has been paid. If it has not. take further action as needed. Non-Covered Services It is important to understand what you have agreed to as a contracted provider, as well as what the patient lias agreed to by purchasing a specific insurance plan. You must know the details of your medical review policies to be aw are of when certain carriers don't allow billing for specific codes, and whether you are allowed to pass those costs on to the patient, or if they are just "not covered" and you essentially cat the cost of it if you perform the sen ice. Understanding these nuances up front saves you time, stress, and worries over unpaid sen ices, and helps you save face with the patient. It is far easier to explain a patients financial responsibility during your financial report of findings (FROF) than months later when you find an unsupported, non-covcrcd sen ice code denied several times fora course of treatment. Understanding the rules of the game is essential to positive cash flow. For carriers you deal with often, keep a list or a "cheat sheet" of unsupported, non-covcrcd codes so that clear communication can occur during the FROF and every sen ice provided is included for payment. Make sure you understand the carrier's policy on billing patients for non-covcred sen ices, and if a specific form or advanced notice to the patient is necessary in order to make the patient responsible for these sen ices. For example, many carriers" medical review policies clearly state that they will not cover roller table-type traction, usually billed as 97012. So if you utilize a non-covcrcd "Spinalatof-typc traction table, arc you able to provide the sen ice to the patient with advance notice and approval for the patient to pay instead? It's ven important to know this before the denial occurs, or worse yet. after an audit discovers that your 97012 codes billed and paid were actually roller table traction. Single Code or Bundling Denials Sometimes an insurance carrier will deny a single sen ice code but pay all other sen ices billed for the date. Investigate the reason for denial. If the code is deemed to be included with the payment for another code, often described as "mutually exclusive." make sure modifiers were properly appended, or determine if this is the best code to describe the sen ices rendered. If a modifier is necessary or your documentation supports a different code to describe the sen ices, you may be able to send in a corrected claim to be properly reimbursed for your sen ices. Be sure to read remark codes to understand the reason for denial, and then move forward appropriately based on that reason. Excellent template letters exist throughout the profession for appeals around bundling. Check out the American Chiropractic Association's website (www.acatoday.org) for a variety of policy-based template appeals when bundled codes arc a concern. Medical Necessity' Appeals These denials arc often the most frustrating. Here is a carrier, miles from your office, making a determination about your patient w hen they have never met the person. It's appropriate to roll up your sleeves and fight for your patient, but first determine if your documentation tells a believable story of why the patient is receiving the care you deem necessary. Docs your documentation include a treatment plan with functional goals? Is the patient's functional improvement noted and show ing progress toward your stated goals, but requires more care to get there? To ensure you have a leg to stand on for a medically necessary appeal, make sure your documentation includes: A clear functional deficit related to the goal of your treatment for each region you're treating A diagnosis that is supported by objective findings for each region you're treating A treatment plan, including functional treatment goals, for each region you're treating Notations that explain how the patient is responding to treatment • Explanation of why the full recovery of the functional loss is not yet achieved and what is left to accomplish Documented support of the codes that were billed Once you have determined that you arc prepared to fight a medical necessity denial with your records, gather all the information for this patients episode of care that surrounds the denied sen ices. Start with the examination and include all documentation through patient discharge to send to the insurance company. It makes the most sense to summarize your care in plain language on a cover document sent with your documentation. This helps the insurance company understand your treatment more thoroughly, and raises your chances of them reimbursing you for sen ices rendered. Commercial Claim Appeals Once you"ve addressed the reason for denial and arc sure that your documentation will support your appeal, then roll up your sleeves and begin the process. Is there a time restriction for appeal? If so. mark it clearly and meet the deadline to avoid an additional denial. Ensure you have a system created to work your appeals at regular intervals in order to keep from missing the opportunity for appeal. This is one of the most common denominators that providers find when facing unfortunate A/R reports. Gather documentation and synopsizc the case using a case summary letter as a cover sheet. Your letter should include a brief statement and a list of what is included, such as: Attached you will find supporting documentation to substantiate the medical necessity of the treatment provided by our office. Included in the packet of material is: (Include all that apply) A letter of medical necessity outlining the need for care Copies of office notes, exam findings, treatment plan(s). diagnosis, history form(s). outcome assessment tools, x-ray findings, other diagnostic findings, discharge form Patient "s attestation of their need for care Reports or documentation from other healthcare providers for coordination of care during this episode Copy of the denial or EOB in question Your letter should also summarize: The episode of care dates—beginning and end Whether the care was for acute or chronic conditions What the exam/x-rays indicated How the subluxation was demonstrated The diagnosis codes assigned Total number of visits for this episode (include the visit number for dates in question) When rc-cxaminations occurred How treatment effectiveness was measured Patient discharge or expected discharge date Conclude your letter with a statement such as. "Hopefully this information assists you with understanding our position that the visits in question arc indeed medically necessary. Don't hesitate to contact us should you have questions about this material." Medicare Appeals Medicare has its own published appeals process, which you must follow for Medicare appeals. The Medicare Part B administrative appeals process is available to beneficiaries, providers, and suppliers dissatisfied with the initial determinations and subsequent determinations and appeal decisions. An initial determination is defined as the first adjudication (judgment) made following a request for Medicare payment for Part B claims under Title XVIII of the Social Security Act. The notice of initial determination, which is the Medicare remittance notice (MRN). will outline and include the appropriate appeals information about how to file. This initial determination (MRN) is binding unless a party to the initial determination makes the request in writing to appeal. Medicare has five levels of appeal, these include: First level: Redetcrmination. which must be filed within 120 days of initial determination Second level: Reconsideration by Qualified Independent Contractor. which must be filed within six months of the review determination • Third level: Administrative Law Judge, which must be filed within 60 days of QIC decision Fourth Level: Appeals Council Review, which must be filed within 60 days of hearing decision/dismissal • Fifth Level: Judicial Review in US District Court, which must be filed within 60 days of Appeals Council decision It has been reported that more than 50% of claim denials are overturned within the first three lev els of appeal, so why wouldn't you? There arc monetary thresholds for some levels of Medicare appeals. It is important for you and your staff to understand each level of the Medicare appeal and how to use this to your advantage when defending your claim. These levels of appeal for Medicare do not include rejected claims for clerical errors. Rejected claims must be corrected and rcsubmittcd as new claims. Rcdctcrminations for claims rejected as being unable to be processed will not be honored. If a claim you have submitted contains a small clerical error or omission (e.g.. transposed numbers, mathematical mistakes, computer errors, etc.). this maybe corrected through the reopening process and not through the appeals process. Be Prepared Understand your most common denials by reviewing denials regularly. If certain denials arc common, create template letters to keep handy for easy appeals. Dont forget to use your resources, such as your state association and the American Chiropractic Association, to help fight for your rights concerning appeals if you feel you arc getting nowhere with the insurance companies. Take the time and make the investment to fully train your CAs to understand the systems and processes necessary to ensure payments for your services rendered. A streamlined and active appeals process in your office will ensure proper reimbursement and a thriving business. Kalhy Mills Chang is a Certified Medical Compliance Specialist (MCS-P) and. since 19S3, has been providing chiropractors with reimbursement and compliance training. advice and tools to improve the financial performance of their practices. Kalhy is hum n as one of our profession sforemost experts on Medicare andean he reached at f855) TlirlMKMC or info&kmcuniversity. com
