A report published in the Medscape Medical News in March 2022 revealed that only 0.2% of the denied patients’ claims go back to the appeals process in medical billing. However, the same article also said that the success rate for the appeals process is around 50%. Despite the Affordable Care Act 2010 rules aiming to make the process simpler for consumers, why is it that so many people do not want to approach this path? What are the complexities that are disrupting the procedures? This article will take you through the appeals process in medical billing and the key aspects you need to keep in mind to maximize the revenue flow in your organization.

Awareness of Appeals Processing

Lack of awareness is a vital issue that leads to failed or no appeals process in medical billing. According to lawyer organizations dealing with appeals in healthcare organizations, a lack of awareness is present both in the provider’s office and the patient’s side. For example, in the case of patients, most of them do not know that there is an established process in place. Even if they knew about the existence of such a system, they did not know how to approach such a complex process.

Medical organizations are undoubtedly aware of the existence and functioning of the appeals process in medical billing. However, each provider’s office deals with several insurance companies to process their claims. Each private and Government insurance panel has its filing method for appeals. The in-house teams at healthcare organizations are often not prepared to handle the unique requirements, leading to failed attempts. In-house teams at these organizations lack awareness of the different workflows these insurance panels follow.

The teams need frequent staff training to understand how the different appeals processes work for insurance organizations. For example, there are separate islands of dedicated teams specializing in different insurance company workflows in leading professional medical billing services companies. If you feel too overwhelmed with a staff shortage at your organization, get in touch with an experienced revenue cycle management company for better returns.

What are the hindrances?

There are several hindrances that healthcare organizations encounter in the appeals process in medical billing, which leads to lower revenue realization over time. Here are some of the points that the article highlighted:

  • Healthcare providers are extremely burdened with their regular medical and administrative work. Taking up the responsibility of a complex procedure like the appeals process makes it cumbersome. Most healthcare professionals do not appeal for the claims and leave money on the table.
  • The other thing that keeps providers from successful appeals is the medical necessity documentation. Proof of medical necessity is an intrinsic component of the appeals process in medical billing. However, healthcare providers cannot always support the exact needs of the insurance companies, due to which the appeals get denied. Due to this reason, several independent providers do not go for the appeals process in the first place.
  • The provider offices are often shy of using software solutions that help them track the appealing procedure’s step-by-step process. Manual errors and staff shortages often make it more difficult for the in-house teams to manage the complexities of such operations. Incorporating technology into your everyday workflow pattern will help you overcome these issues and make sure that you stay alert to its pitfalls.
  • Insurance companies have a specific time boundary on the appeals processing system. So the teams handling the appeals process in your organization should be prepared to meet the deadlines. However, due to the manual handling of these procedures, most teams fail to keep up with the calendar, leading to failed attempts at appeals.

Medical Necessity Documentation

Medical necessity is often the reason why insurance companies deny your claim. While it serves as a good screening process, it could be a real factor of contention between the provider’s office and the insurance companies. The best way to fight your cause is to support your appeal with the necessary documentation.

According to an article published by the AAPC, here is how you should approach your medical necessity documentation for a foolproof appeals process:

  • Make sure you list the top condition or diagnosis for which the treatment plan occurs.
  • Assign the highest regard of specificity when coding the services
  • Use appropriate descriptions for each specific case of patient illness.
  • Do not forget to mention any acute outcomes of emergencies—for example, hemorrhage, loss of consciousness, and coma.
  • Chronic complaints are crucial factors in substantiating your claims regarding medical necessity.
  • Make sure you supplement these chronic factors to establish a chronology to serve as excellent support for your medical necessity argument.

Equip your existing teams to manage the patient’s medical accounts with appropriate papers, test results, and diagnostic history to attach these files to add more credibility. You can also partner with outsourcing medical billing companies to get your job done without investing too many resources.

Establish a Proper Workflow  

Most organizations suffer from undefined workflow management regarding the appeals process in medical billing. Taking a targeted approach or handling the system case by case often leads to issues with the management process. Healthcare leaders advise that you should have a repeatable process in place to boost your efforts to increase your revenue flow.

Analyze your current appeals success rate and find out which loopholes are holding you back. Make sure that you have a dedicated team of specialists in your team to maximize your cash flow. Establish a structured documentation process for storage and retrieval to back up your appeals correctly.

We hope this blog helped you understand how to utilize your appeals process in medical billing to maximize your revenue. Please comment on your suggestions below. For more information on healthcare financial management and billing services, please subscribe to our blog and follow us on Instagram, Facebook, Twitter, and LinkedIn.