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How to appeal an insurance reviewer’s decision

March 10, 2011

Insurance claims are a primary source of income for many medical practices, and a coverage request denial can hurt a provider’s bottom line.

The main reason a request is denied is usually because of bad documentation practices, inappropriate care or cases where the care was appropriate but doesn’t fit the literature or guideline language, Dr. Nicholas Fogelson writes for Taking good notes and cross-checking a patient’s request for care before an appointment are both preemptive defenses against a rejection.

Here are Fogelson’s tips on how to appeal if an insurance company reviewer does reject a claim.

First, write a letter summarizing the care of a patient, including symptoms, previous treatments, current diagnosis and what future treatment is planned. It will save the reviewer the trouble.

Try to stick to evidence-based medicine, Fogelson writes, as the treatments can be backed up with literature and are more likely to win an appeal. If a doctor is using controversial treatments and is appealing a rejection, address the controversy in the summary letter.

Again, thorough documentation of patient care is a key aspect of winning an appeal. Electronic health records can be extremely useful in this case, because they are legible and doctors may be more inclined to type details that they wouldn’t take the time to write by hand. Including the evidence and thought process that led a doctor to conclude a procedure was necessary is more likely to win an appeal than two lines explaining general symptoms and what treatment is planned, Fogelson says.

When a doctor does send in the appeal package, he or she should try to limit the information to only what’s necessary and justifies the appeal.

During the appeal process, doctors should not lash out at the reviewer and shouldn’t give up after one appeal, Fogelson writes. If a physician truly believes in a case, taking the time to fight for it may pay off the second time around.

Practices can work to reduce the risk of rejected claims by proactively screening patients for insurance eligibility, which can improve revenue cycle management. As Rose Marie Nelson writes for MedPage Today, the cycle begins when a patient calls an office to set up an appointment.

This is the time for staff to ask a few questions about insurance coverage, which can help the practice determine whether it will get paid for its services and can also save doctors the trouble of appealing insurance reviews later.

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