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How to Appeal Denied Claims

Julie McCoy, for HealthLeaders Media, January 10, 2011

Denied claims are just a part of doing business, but that doesn’t mean you can write them off. You knew it was a legitimate claim when you submitted it, so you should be willing to fight for the money you are rightly owed.

But how do you successfully appeal a denied claim? What strategies work and when do you know it’s time to cut your losses? For starters, look at the appeals process as a normal part of business and not an improvised response to an unexpected denial. After all, the denials aren’t really unexpected.

Providers should consider the appeals process a routine part of managing the practice’s revenues and have a standardized, formal plan for appealing denied claims, says Shelly Cronin, CPC, CPMA, CANPC, CGSC, CGIC, director of business and member development for the American Academy of Professional Coders in Salt Lake City. That means having at least one person in the office who understands the appeals process and is responsible for appealing claims quickly and effectively.

The provider also should have a policy that clearly states what your appeals process is, Cronin says. New staff can refer to the policy and existing staff can be held accountable to following the process outlined there, she says.

“One of the most common problems is not appealing in a timely fashion,” Cronin says. “Once that claim is denied, you only have a certain amount of days to file your appeal and get it looked at again. A lot of people will let these denials stack up rather than addressing them quickly, and by the time they get around to them, they find out that the window has closed on some of the claims.” 

Cronin recommends following up on denied claims at least once per week, and possibly more often depending on the volume of claims and denials. The appeals process should include documenting the reasons for the denials and the eventual outcome, and then using that information to educate coders so you are not dealing with the same denial issues over and over again, she says. 

Bundling similar denied claims and appealing them all at once can improve efficiency, Cronin says, but that strategy runs the risk of interfering with the required time frames.

“So you have to balance that effort to be efficient with meeting those deadlines. You haven’t achieved anything if your efficiency is offset by losing money on the claims that expired,” she says.

Managed care companies have their own rules about how long you can wait before appealing, as well as their own preferences for how they want appeals submitted. It is to your benefit to know each insurer’s timelines and processes, Cronin says. Keep a notebook that outlines each insurer’s specifications and quirks for easy reference, she suggests.

“If you don’t know what your payers are requiring for a timely appeals process, you are really taking another step back, setting yourself back even further than when you had the claim denied,” she says.

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