How to Appeal Denied Claims

Julie McCoy, for HealthLeaders Media , January 10, 2011

Call the payer right away

Appealing improperly is almost as bad as not appealing in a timely fashion, Cronin says. Some providers have a stock appeal letter that they send out for all denied claims—that’s a bad idea.

“If you’re sending out these stock appeal letters, they’re just going to be denied again because it is not pertinent to why the claim was denied in the first place,” she says. “A lot of places use the stock appeal letters, and when it is denied again, the staff can say, ‘Well, we tried,’ and let it go. That’s a waste of money that you are rightfully owed.”

The first thing you should do when you receive a denial is call the insurer for more information, Cronin says. Ask why the claim was denied, even though the reason will be stated in the denial. By talking to someone about the claim, you often can glean more useful information that will help make your appeal letter more focused and convincing, she explains.

“In some cases, the problem may be something simple that can be resolved over the phone,” Cronin says. 

Send a proper letter with appeal

When submitting an appeal, make sure you get the details right and don’t cut corners. Don’t merely send the denial letter back with a note on it, Cronin says. Use a cover letter that states your reason for disagreeing with the denial, and provide any written backing for your position—any information that demonstrates why you coded the claim the way you did and why the insurer should pay it. This could be information from the payer’s own guidance, Medicare, or CPT coding guidelines, Cronin says. 

“Or have your physician write you a paragraph or a letter explaining why they wanted to use a certain procedure or take a certain action with the patient and why it was medically necessary,” she says. “The more information you can add that is pertinent and fact-based, the better. You don’t want to get emotional and demand that they pay this or criticize the process. Be polite and professional.”

Don’t resubmit a claim without explanation, says Bill Gilbert, president of AdvantEdge, a Warren, NJ–based company that provides billing services, practice management, and coding for specialty physicians and surgery centers. The carriers don’t like that and will reject the claim again.

“It clears the paper off your desk, but you’re just deceiving yourself. It doesn’t accomplish anything and, in fact, it just further delays the resolution,” Gilbert says. 

Keep a paper trail on all denials and hold on to them for future reference. When you receive a similar denial in the future, you can refer back to those earlier claims to see what worked in the appeals process with that insurer, Cronin says.

Watch for omissions, simple errors

The most common cause of denials is usually related to the insurance information submitted with the claim, explains Gilbert. For instance, the insurer may deny a claim by saying that the patient is not insured with that company. Instead of huffing and puffing about the insurer’s error, look for clues as to why you got that response. “Often it’s just because the insurance number was entered wrong somewhere. Maybe a couple of numbers were transposed and the insurer’s computer kicked it out when it couldn’t find that incorrect number in the system,” Gilbert says. “If you can find that error, you can resubmit the claim with a letter explaining what the problem was and providing the correct information.”

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