Patient Advocacy: Healthcare on your side
by Martine G. Brousse,
Healthcare
Specialist, Patient Advocate, Certified Mediator
ADVIMEDPRO
4 Tips for Successful Insurance Appeals
In the mysterious world of insurance appeals, final determinations are
based on the merit of your grievance, your insurer's
policy and your plan benefits. Following these tips may lead to better
outcomes.
1. Know the Facts
Providers should be initiating the vase majority of appeals. They have
the medical, coding, and technical knowledge to do so. If they
refuse, or are unable to do so, you should, at a minimum, receive all relevant
supportive documentation.
If a claim was rejected for billing errors (incorrect codes, diagnosis
ID, etc), filing an appeal is a waste of time as only a processed and paid
claim can be appealed. Your doctor's billing person should resubmit corrected charges,
or provide your insurer with any requested documentation.
If a charge is rejected as "non-covered, not a benefit of the plan,
not reimbursable under the insurance guidelines, experimental, off-label, not
medically necessary or out of network", a talk with the office manager at
your office is in order. Was this info known to the office but not communicated?
Were your benefits verified before services were rendered? Is it a simple clerical
error?
Answers will determine whether this is now appeal material, an financial
issue between you and the provider, a third party responsibility (i.e. an
incorrect dx given to the lab whose claim was rejected) or your own error (i.e.
you did not share your new ID card).
2. Who should appeal?
If the office is responsible, it should take immediate corrective steps, send
records, or update information.
Billing mistakes made by secondary providers (labs, imaging centers) are
common. Call them to give your new insurance ID or address. Many denials occur
when invalid or non-payable diagnosis codes are forwarded with the order or
prescription. Your MD cannot be expected to know each payable dx for every
outside service. Updating the order in your chart must be completed before the
appropriate biller can resubmit the charges with a payable code.
If information was withheld from you, either deliberately or by
ignorance, insist the office appeal to your insurer with comprehensive
explanations and detailed clinical justification from accepted sources.
Best undertaken by both the patient and the provider, this process calls for
payment due to "medical necessity".
If you had no choice or option, and are being billed for services
considered "out of network" or "non covered", do file an
appeal, especially if these were rendered under emergency conditions.
When in doubt, go ahead and file. You are within your rights to ask that
your claims be reviewed, and your financial responsibility confirmed.
3. Be Clear and precise
Why you are requesting the review of a charge? Asking your insurer to
reprocess a claim just "because they did not pay or not enough"
almost guarantees a denial of your request. Computers process claims, not
people. They seldom make mistakes (computers not people!). As an actual person
will review your appeal letter, the exact reason(s) of your request should
be clear.
Invoke your right to a "continuation of care" level of coverage
if your Dr cancelled his/her contract in the middle of treatment and
claims were paid "out of network". Demand payment of non-contracted
charges based on your emergency hospitalization as the law states. Demonstrate that "medical
necessity" was met for a prescribed treatment or procedure by using your medical
records, and supportive industry or Medicare guidelines. Ask for a reversal of
a denial based on specific and unusual circumstances. Brand drug manufacturers offer
ready-made sample letters to appeal coverage of their products.
4. Attach relevant documentation
Documentation is essential to any appeal. No or little documentation =
not much hope of success.
While I would not recommend sending truckloads of papers to the reviewer,
ask the staff to provide the most appropriate clinical records to make your
case. Ask them to direct you to related websites, significant studies, important
links and online resources to add supportive documentation.
You may need to request records from a third party, usually the physician
who ordered a specific lab, test or imaging service, in order to get medical
justification and prove medical necessity. Remember to include the
original order or prescription with your attachments.
Mail a copy of the appeal to the related provider, and ask for the
financial responsibility to be shifted back to the insurance during this
process. If the provider refuses, make small monthly payments to
keep your account current, show good faith and avoid collection action.
© [2016] Advimedpro.
© [2016] Martine G. Brousse.
All rights reserved.
My
objective is to offer you, the patient, concrete and beneficial
information, useful tips, proven and efficient tools as well as
trustworthy supportive advice as you deal with a system in the midst of sweeping adjustments, widespread misunderstandings and complex requirements.
AdvimedPro (424) 999 4705 or (877) 658 9446 fax (424) 226 1330
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