• Practice Solutions

What is a claim appeal and how to do one?


Main Points

  • A claim appeal is when a therapist wants to dispute a claim decision by an insurance company based on medical necessity or errors made on the part of the insurance company

  • Each insurance company has their own appeals process and each has very specific requirements in order to process an appeal

According to CMS and the ACA, patients and providers have the right to a fast appeal. Unfortunately, this rarely happens and it can impact your practice and patient care in large and harmful ways.

So what are you to do to rectify the situation and navigate the appeals process. Throughout this blog we are going to discuss what a claim appeal is and why a provider would want to complete a claim appeal, explain the national rules that each insurance company must adhere to, and set reasonable expectations around when you should expect an answer from the insurance company on the appeals that you have sent.

A claim appeal is when a therapist wants to dispute a claim decision by an insurance company based on medical necessity or errors made on the part of the insurance company. This can be an uncomfortable decision since it will take time and effort to walk a claim from start to finish through the appeal process.

However, if you decide to begin this process, there are 5 things that you will need to know in order to navigate the process well:

  1. If you decide to file and appeal, gather all the necessary medical and clinical documentation that you feel will help your case. This is critically important since the insurance company will review your appeal and see if there is a clinical or medical basis for your request to appeal a claim decision. Be sure to put as much thought into this part of the process as possible so you can ensure a positive outcome.

  2. If you think your patient's health could be seriously harmed by waiting for a decision about a service, ask the plan for a quick or expedited decision. If the plan agrees to do so, the insurance plan must make a decision within 72 hours. This is a little known fact but an important one! If you believe that your patient's will be harmed be sure to communicate that as clearly as possible to the insurance company and ask for a quick decision. Be sure to follow up with them as frequently as possible.

  3. The insurance company must tell you in writing how to appeal. After you file an appeal, the plan will review its decision. Often times, insurance companies will use a third part to review the claim to ensure an objective party is present. Since the appeals are reviewed by an outside party you will want to make sure that you are following up as frequently as possible because breakdowns in communication can occur and you would not want that to delay the decision.

  4. If you believe that you are being treated unfairly, you have a right to immediate review by a third party. You will be able to request immediate attention by contacting the provider service representative assigned to your practice or geographic area. Ask them to set a meeting with you to go over the details of your appeal or your claim woes. Explain to them that the delays in claim processing or payment are hindering your patients and need to be resolved immediately.

  5. You have the right to fast track appeals processes when you disagree with a decision. This will come in the form of writing from the insurance company or it is laid out in the provider manual that you were given when you joined the panel.

Follow these simple guidelines to help guide you through the process of appealing your claims.

Each insurance company has their own appeals process and each has very specific requirements in order to process an appeal. Before going down the long road of appeals you will want to know, with a great degree of specificity, what the insurance company's appeal process looks like.

Each insurance company has their own forms and process, so it is crucial that you are familiar with their process so that your claims are not further delayed or denied because a step was missed.

Here are some tips to help you through the process of determining the appeals process:

  1. Obtain a copay of the appeal form from the payer website

  2. Look through the provider handbook for a chapter on appeals and follow the guidelines to a T

  3. Contact your provider area representative to help you through the process

  4. Look at the Explanation of Benefits for each claim to see if there are appeals processes

  5. Submit your appeal in a timely manner

  6. Follow up on each appeal that you send in

These simple steps should help you through whatever insurance company you are trying to deal with.

The biggest piece of advice we could give you is to track all your correspondence and ensure that you are following up on the status of the appeals as frequently as you can so they don't get lost in the shuffle.

While these tips and tricks are valuable, they can cost you significant amounts of time. The amount of time that a denied claim and appeal can cost can amount to 8-12 hours a piece. That means that every hour that you are not spending in a session or working on your business you may be losing more than just your denied claims.

If you are curious about whether you are missing out on claims or want a leader at PS to look at your claims and give you an evaluation, feel free to reach out by phone or by email and we would be happy to look at your claims and make sure that you are capitalizing on all the claims that you have submitted.

#Claimappeals #CMS #ACA #Affordableclaimsact #escalation #processanappeal

2 views

© 2017 PRACTICE SOLUTIONS, LLC