Collecting Lost Revenue

Tips for Appealing Denied Claims

A report by the Government Accountability Office (GAO) shows that many claims are denied because of mistakes with billing and coding. Providers may be able to recoup some of that lost revenue through the appeals process. The report explains that 50 percent of all appealed claims were paid after an appeal was submitted.

The burden of submitting the appeal typically falls on the physician, a task which is not made easier by the fact that there is no set standard appeals process for private payers. These are our tips for submitting a successful appeal.

Understanding the Reason for Denial

Review the explanation of benefits for the denial reason(s) to provide an appropriate response in your appeal. The most common reasons for denials include:
  • Use of incorrect CPT/HCPCS code(s)
  • Incorrect number of units billed
  • Transposed, missing or truncated policy numbers
  • No prior authorization on file
  • Missing prior authorization number on claim
  • Patient’s insurance mandates the use of a specialty pharmacy and office used buy and bill method
  • Benefits were not verified prior to service being provided

Appealing the Claim

Contact the payer to obtain their appeals process. Elements to consider in your inquiry may be:
  • Your ability to fax or submit the appeal via fax or electronically (on-line)
  • Address and phone number for their appeals department
  • Payer-specific timeline and process for responding to appeal requests
  • Is there a payer-specific appeals form that must be completed?
  • Name and phone number of your provider representative
  • Name and address of their medical director
  • Payer-specific timely filing limits (check your contract for timely filing rules with the payer)

Source: 'Appealing an Insurer’s Denial is Often a Good Strategy', Kaiser Health News.

This information was provided to Besse Medical by Xcenda.