Step by step guide to Maximize Appeal Chances for Medical Billing Companies

Appeal process can be really challenging for healthcare professionals as it involves time to deal with the insurance companies.

Medical Billing companies rescue healthcare professionals from their claims being denied or rejected by insurance companies. They literally knock the doors of payers until the payment is received on time.

It isn’t that easy to pull out revenue from the payer after meeting with claim denials. Healthcare professionals can choose expert Medical Billing Companies to fight the claim denials leading to revenue loss.

Here are few tips to maximize the chances for appeal process:

1. Understand Your Claim Denial:

• Before you decide to fight for the denied claim, it’s important to understand why the claim was denied in the first place.
• Verify the Explanation of Benefits along with the key to the codes provided by the insurance companies that explains the reason for the denial.
• If not clear, don’t hesitate to call the payer to find out the exact reason for the denial.
• You can check with the payer to have an appeal on the particular claim submission.

2. Avoid Errors:

• Common denials would always include simple errors in the data entry or patient demographic details or a misspelled name and incorrect ID number.
• If anything found earlier, please ask the payer to correct it before processing so that it might remain in the safe zone.
• If the error is something to be re-corrected by the healthcare professional, then the claim should be corrected and submitted within timely filing limit.

3. Evidence or Proof:

• Maintain a record of the call history with the insurance companies as an evidence to file an appeal.
• Make sure to have all the required documents of the complete insurance coverage.
• Maintain paperwork and always have a copy before submitting to the insurance companies.

4. Timely Filing:

• Pay attention to the timeline. Never forget to have a regular follow up with the claim.
• Resubmitting the claim within the specific mentioned time is the work to be done first of all.
• Set up a reminder to file the claim within the timely filing limit otherwise you may lose your payment.

5. Don’t hesitate to take it further:

• Claim denial doesn’t sound happy for a healthcare provider.
• But if the claim is denied for the second time, then you will have one more chance to get your work done.
• It requires an appeal process or an external review process in order to process your claim successfully.
• Internal appeal process also can help to move this issue faster.

Why Claims are denied?

• Medical Billing companies undergo certain procedures to submit the claims.
• Any errors or mistakes in the claims won’t be processed by the insurance companies. Therefore the claim is either denied or rejected.
• Sometimes the service provided by the healthcare professionals would be different from the service coverage mentioned in the patient details.
• Such claims will be resent to check the details once again and resubmit those claims within the time limit.
• If the patient is not enrolled in the insurance plan or does not hold the coverage for the services rendered.
• Insurance companies will have certain protocols according to regulations of the company.
• If specific medical service does not come under the payer’s policy, then there’s a chance for payment denial.
• If the documentation is not proper and appropriate to support the reason for performing medical procedure.
• The referral number on the file may be invalid. Insurance companies might find it as valid point to deny the claims.
• Patient demographic details are very important to submit a claim. Valid and accurate information should be provided in which age, ID number and name of the patient is mandatory.
• Medical Billing companies take the responsibility to spend more time on the appeal process for the denied claims.
• This procedure helps healthcare professionals to recoup money and brings a systematic growth in revenue.

Claims Re-submission:

• Claim denied due to incorrect documentation or invalid coding will be resubmitted with all the required information within the timely filing limits.
• Medical Billing companies must insist their medical billing teams to include the required information in order to process the claims without any obstacles.
• An updated copy along with the previous claim copy would be required.
• A copy of remittance advice which was incorrectly paid.
• All the required documentation by the insurance companies.
• Identify those documents with the word “Re-submission” to avoid repetition of the same documents.

Two ways to Appeal a Claim:

1. Internal Appeal
2. External Review

Internal Appeal:

• When a claim is denied or rejected by the insurance companies, medical billing companies has the right to file an internal appeal.
• It is an appeal process to ask the insurance companies to review the claim and make a fair decision on claim submission.

External Review:

• When the internal appeal fails, it’s the right if the healthcare professionals or Medical Billing companies to approach external review by making an appeal to third party.
• It means that the insurance company no longer gets to say the final decision of the revenue payments.

How to file an Internal Appeal and External Review:

Internal Appeal:

• Gather the copies of Explanation of Benefits (EOB) that states the payments and services those were denied.
• Copy of documents if any additional or further information with the insurance companies.
• Phone call records and notes of the insurance companies that relates with the appeal.
• Make sure all the documents are valid and accurate.

External Review:

• If the Explanation of Benefits (EOB) or the final denial documents are unavailable, better find the external review information of that particular State.
• According to the law, insurance companies must abide by the State’s rules and participate in the external review.
• Find the best Medical Billing Company which is familiar with the medical procedure to file an external appeal.

Must-Have Elements in an Appeal Letter

Updated and correct details concerning the medical claim are paramount in any procedure related to the administrative process. Here are the major elements you should include in your appeal letter to help the insurance companies navigate better.

• Demographic details of the patient. This includes name of the patient, Policy number, Name of the Policy holder.
• Updated contact details of the patient along with the policy holder, if both are different
• Name and contact details of the medical provider who has conducted the healthcare services
• Pointers on the denial letter along with the date of denial. This includes the services carried out, specifics of the medical service for which reimbursement was denied and reason given for denial.

How to Present your Case

Make sure you include compelling points on why your denial should be reversed. This will make your appeal letter stand out and fetch positive results for the revenue cycle.

• Cite the details of the particular plan lineage in question to back up your claims.
• Consider attaching a letter of medical necessity from the provider with details of previous treatments.
• You can also provide precedence from reputed and credible journals or industry-recognized groups to highlight the importance of the medical service in question in realizing better clinical outcomes.
• Do not miss out on any credible piece of information from authoritative sources to add authenticity to your claim. This can include a letter of recommendation from physicians in the form of second opinions or pre-authorization paper, if any.

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