Select Page

Industry Insights

Best Practices for Appealing Medical Claim Denials

By: Beth Madden, Client Administrator

RCM case study: lazy appeals

In reviewing a pathology client’s monthly adjustments report, I noticed there were multiple instances of “appeal denied-adjust per policy” write-offs. Because of the success I had with appeals prior to my Lighthouse/Vachette days, I asked to review the appeals, which the biller sent to me, albeit reluctantly.

I then received copies of the pathology reports, claim forms and appeal forms/letters. Without fail, the approach from the biller was to simply reply, “see attached documentation. Please reprocess for payment.” If I were processing appeals, I would have denied them too! That is insufficient information for someone to process an appeal.


A more successful approach to appealing medical claim denials

Billers and revenue cycle management teams need to keep in mind that most people responsible for processing appeals are not medically trained, so it must be made painfully clear in the appeal why the claim should be paid. As the number of denials for Medically Unlikely Edits (MUEs) becomes more common, billers must be putting forth every effort to collect every penny.

Keep in mind that MUEs are not Medically Impossible Edits, so let’s not treat them as though they are. Granted, you may not always get as many biopsies (for example) processed and paid as were performed, but you must try. But what’s the most effective approach for doing so? While in this instance the biller turned down my offer to assist them with their appeal letters, others in this position need to make very clear why the services performed deserve to be paid.


Detail, detail, detail

For someone who does not review pathology or lab reports on a daily basis, it is not enough to simply ask them to review it and expect them to understand it. Billers need to explain, in detail, how many biopsies (or other service) were performed and highlight, or even circle them on the report so the payor can match it what was billed.

Once you’ve done that, you must explain why this service was performed. You can highlight the different sites of the biopsies/specimens and explain the billing was supported by the use of modifiers. It is important to make sure the payor understands pathologists do not have a choice to set aside biopsies/specimens that come their way. They are required to examine each one, and therefore, deserve to be paid for doing so. An MUE, or other denial, does not negate the fact that the services were not only performed, but were performed in good faith and deserving of payment.


Pick up the phone!

If the appeal is denied, and you need additional information to support medical necessity, pick up the phone and call the provider! I have not met a pathologist or lab yet who would not be willing to spend ten or fifteen minutes explaining what you need to get the claim paid. Type up the provider’s explanation, get them to sign it, and send it with your appeal. One tactic I like to use is to say, “if your medical director feels the service was not medically necessary, he/she may contact Dr. X directly to explain why.” (Not once has a medical director contacted a provider, in my experience).


Next steps

If your biller isn’t appealing medical claim denials to the fullest extent possible, or if you need someone to review those denied appeal adjustments, Lighthouse Lab Services’ RCM Consulting Team can help you find a more successful approach. Contact us today for a free consultation to learn more!


Sharing is caring!