How to Successfully Navigate Appeals
Even with the temporary suspension of RAC reviews, hospitals continue to deal with insurance denials from a multitude of third party payers.
Responding to these coding denials is time consuming. HIM, revenue cycle and coding professionals are further frustrated when they believe their cases were correctly coded from the start. Despite their aggravation, hospitals must respond to coding denials and navigate the appeal process in order to receive payment for dollars they’ve rightfully earned.
The following eight tips provide guidance for effective appeals and coding denial resolution:
- Submit complete medical record documentation with the appeal.
- Enlist the participation and signature of the attending physician.
- Outline details in your appeal letter to substantiate your initial codes. Include pertinent clinical findings, official coding guideline references and specific notation of record documentation location (i.e. 6/8 hospitalist progress note). Be direct, succinct and to-the-point when addressing the issue of contention outlined by the denial letter.
- Don’t hesitate to ask for reconsideration if you feel strongly the record was coded correctly and is supported by the documentation and official coding guidelines.
- If a coding issue is discovered during review of a denial, share it with all coding staff so the same mistake isn’t made again.
- Keep track of denials and appeals. Use your denial and appeal data to identify trends and determine root causes of denials, taking steps to avoid similar future issues.
- Always share denial findings with other departments involved in the revenue cycle process such as CDI, administration, physicians and case management.
- Good communication helps prevent denials due to other root causes such as insufficient clinical documentation, medical necessity concerns, improper eligibility/authorization, invalid inpatient admission orders, and incorrect discharge disposition.