In the world of EMS billing, claim underpayments and denials are an unpleasant certainty. Whether it’s due to coding errors, insufficient documentation, or questions of medical necessity, underpayments and denials can significantly impact your revenue cycle. However, all is not lost when a claim is underpaid or denied. You have the option to file an appeal. While it’s frustrating and time consuming, knowing how to successfully navigate the appeals process can mean the difference between lost revenue and timely, complete reimbursement.
Before diving blindly into the appeals process, it’s essential to understand why the claim was underpaid or denied. Missing or incomplete documents that failed to establish medical necessity? Coding errors? Lack of pre-authorization for non-emergency transport? Non-covered services? Were out-of-network benefits applied? Once you identify the reason for the underpayment or denial, you can start building your appeal. It is also important to know the payer’s appeals process step by step.
When a claim is underpaid or denied, it is important to read the Explanation of Benefits (EOB) thoroughly to determine the specific reason for the underpayment or denial and determine the next steps. Payers may include specific comments or instructions on how to correct any issues if information is missing or incorrect on the claim. The EOB will help determine if the underpayment or denial was due to a billing error, documentation gap, or a misunderstanding by the payer.
When drafting an appeal letter, remember to ask the payer to reconsider the denial and reprocess the claim. You might be surprised at the number of appeal letters I have seen over the years that outline a solid case but never ask for the claim to be reprocessed. If you don’t formally request the claim be reprocessed, the payer isn’t going to volunteer to do it.
Be clear and concise. Summarize the key points of your appeal and reference specific reasons why the claim was underpaid or denied erroneously. These can include the State Department of Insurance regulations, Federal regulations, or payor specific policies. Keep a polite and professional tone throughout the letter. Stick to the facts and avoid blaming the payer or pointing out frustrations with their company.
Once your appeal has been sent, it is important to follow up and track the outcome of the appeal. Document the date the appeal was received and obtain status regularly. Tracking the outcome of your appeals can help identify patterns in payer behavior and measure your success.
It is important in the revenue cycle to understand what percentage of your claims are underpaid and denied. It is equally important to identify if a specific payer has a higher denial rate than others. Identifying recurring issues can be addressed earlier in the process to help mitigate the denial in the first place. Is there a specific code that one or more payers routinely deny? That is information that needs to be shared with the coding department.
Taking a proactive approach to denial management, continually improving documentation, and refining billing practices will not only reduce the number of denials but also strengthen your overall Revenue Cycle Management process.
