5 Points to Remember for Appeals Process in Medical Billing

Appeals process in medical billing is one such area which medical billers and coders focus on when they want to excel in the domain and maximize the revenue for the company. Working in close contact with the insurance payers should be smooth as much as possible if you want to achieve this goal. For each of the technical aspects of denied claims, there are pre-defined rules that the medical billing team abides by. However, appeals process is more than just blindly following the rules.

When you want to make the most out of your revenue cycle management, while efficiently utilizing the workforce at hand, you need to keep certain points in mind. The staff handling the work at ground zero should also be trained with these intricate details so that they implement them properly. This blog has listed some these crucial points to help you scale up your appeals process in medical billing.

1.Do you have a pre-defined strategy for appeals process in medical billing?

When you receive a claim denial, you have to file the appeal according to the rules of the insurance network. Most billing companies or in house teams know how to do that. Then what is the different approach you must take to escalate your revenue? The first step is chalking out a good strategy for approaching the denials. Though the goals of the organizations are unique, here are some pointers for a start:

  • Every claim denied by the insurance company cannot be appealed. So first segregate the denied claims according to their appealing eligibility.
  • Focusing on this list, it is advisable to not waste time and workforce on claims that cannot be appealed.
  • Arrange the appeals according to their value. The greater the amount of the claim, greater is the chance for it to get paid.
  • Knowing your organization specific goals is mandatory if you want to take further effective steps. After the basics are covered, make suitable plans depending on these goals.
  • Make sure that these plans are practical solutions which will prove to be sustainable for the staff implementing the work.

2.Are you keeping tabs on important denial metrics?

The billing team should track down the specific denial metrics to get a clear picture of the financial issues. Here are some tips given by leading billing companies:

  • Keep a real time tab on your claim denial rate. Try to make it more frequent so that you can make decisions at the right time.
  • Try to see if there are any patterns of denials. The patterns might arise out of a repetitive mistake for all providers or a specific mistake for one individual professional.
  • Once the patterns have been identified, try to move on to strategy planning and implementation.

This step will help your team to be more efficient in the future by ruling out the need to track down unorganized claims. Tracking the metrics will also help the management to take required financial decisions.

3.How complicated is your claim denial?

Not all claims denied are complicated. Before taking the issue to a higher level, you should check whether the problem can be resolved in an easier way. Transparent communication with the representative of the insurance payer is a good start. Once you receive your denied claim, you will also receive the reasons for the same. Make sure you study them well before taking the next step.

Check the correct codes and details mentioned to find the errors from your end. It can be easily done if you have an automated tool like domain specific software. Go for the call and the issue might get resolved right away. Ensure that the staff is documenting the details of the call so that it can be used for any further reference. If the call does not work out, you will have to go for the appeal letter.

4.How good is your appeal letter for appeals process in medical billing?

The accuracy and specificity of your appeal letter can be a major breakthrough when appealing a denied claim. Take a look at the following notes to know which mistakes to avoid and how to get better at it:

  • It is advisable not to follow the same standard template for all appeal letters.
  • The procedures for all insurance networks are different. The separate rules should be properly evaluated and kept ready when dealing with the appeals process.
  • The different types of denials also need separate kinds of appeals letter.
  • All details regarding the services rendered, billing amount as well as the guidelines applicable for the particular case must be carefully furnished in the letter.
  • Some details asked by the insurance company are: Name of the healthcare provider, Tax ID number of the practice, NPI number of the practitioner, Patient ID as given by the insurance payer, Demographic details of the patient, date when the service was provided, amount billed as mentioned.

5.How can outsourcing help in the appeals process?

Outsourcing can always be a great option for intricate procedures such as appeals process if you have experienced professionals on board. Leading revenue cycle management companies focus on these specified services to help out healthcare organizations and individual practitioners. You can opt for the complete end to end management or the specialized teams.

Outsourcing the work to top companies helps to reduce the burden on the in house administration teams. They also have years of experience in this industry while working with different kinds of healthcare practices. They will make out tailored and customized plans for your organization keeping in mind the financial goals that you have set for yourself.

Here were some of the crucial questions that you must ask yourself when evaluating the appeals process in medical billing. However, the needs of each organization are different. Make sure you convey your goals to the revenue cycle management company dealing with your organization.

Hope this blog helped you know the points to remember when managing your appeals process in medical billing. For further queries, you can comment it down below. We will get back to you. For more updates on healthcare, technology and management do not forget to subscribe to our blog and our social media handles.




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