How to simplify the claims auditing and appeals processes
1.Know the health plan’s claims appeals processes before you need to submit a claim appeal. Understanding these processes will allow you to acquire the health plan information (i.e., supporting documentation, health plan language) required to prepare a claim appeal.
2. Know where to locate the following health plan policies and, if possible, include them in the health plan contract:
*Claims adjudication procedures (i.e., definitions of complete or clean claims and medical necessity)
* Rates and reimbursement methodology, including a comprehensive fee schedule
* Claims appeals processes
* Rates and reimbursement methodology, including a comprehensive fee schedule
* Claims appeals processes
3. Document, document, document. The supporting documentation of a claim submitted to a health plan must substantiate the performance of a service by the treating physician or health care professional. If a service is not documented, it didn’t happen in the eyes of the health plan—and the claim may not be paid.
4. Review and monitor all claims before submitting them to the health plan to ensure that you are filing complete and accurate claims. One way to avoid a claim denial is to correctly code the original claim. Implement a check and balance system between the physicians and the coding and billing professionals in your practice to determine whether claims are being coded appropriately.
5. Maintain a coding reference sheet in your practice with a list of commonly used International Classification of Disease-9th Edition-Clinical Modifications (ICD-9-CM) and CPT codes, as well as any other commonly reported codes on the standard claim form.
6. Evaluate the health plan’s explanation of benefits (EOB) for accuracy (i.e., potential processing errors, lack of recognition of a CPT modifier, incorrect physician fee schedule).
7. Know your contracted fee schedule rate with each health plan for procedures and services commonly performed in your practice. Review each EOB you receive to ensure the negotiated reimbursement and discount rate with each health plan is calculated appropriately.
8. Maintain a health plan follow-up log that contains the reason the claim was partially paid, delayed or denied by the health plan, and also include the internal follow-up action by the practice staff to reduce future health plan underpayments and denials.
9. When submitting a formal claim appeal letter to a health plan, thoroughly explain your rationale for challenging the health plan’s claim denial. Additionally, include the appropriate documentation to support your request to reverse the denial.
10. Streamline your practice’s claims auditing and appeals processes by maintaining an appeals resource file with appeal template letters, rationales and supporting documentation of previously submitted claim appeal letters that resulted in overturning the denial.
11. Keep appealing. It may take more than one appeal to reverse a health plan’s incorrect denial. When a procedure or service has been appropriately performed, documented and reported, be persistent to ensure your practice obtains the proper compensation based on the negotiated health plan contracted rate.
12. If the appeal is not overturned by the health plan after you have exhausted the appeals process, file for an external review if available through the appropriate state or federal regulatory agency
