Following directions can mean the difference between getting your healthcare claim paid or denied. Every insurance company has a specific appeal payment policy that includes how to file an appeal if you're a provider or a patient. The key is to know what that policy is and follow it exactly.
Most insurance companies have their appeal policies online. Sometimes their requirements, including the appeal form, is somewhat hard to find. In many cases, they'll address appeals under their payment policies or under patient rights.
If you have trouble finding the information you need, use the search function on their website with the term, "appeal form". Most of the time that can help you quickly sift through all the information and get to what you need. If that doesn't work, call their customer service department and ask them where to find it. You don't want to just ask what their appeal policy is - you want them to help you find it on their website. The reason for this is if they give you erroneous information, you won't have anything to fall back on.
Something as simple as leaving a box unchecked, using the wrong form, or not attaching information can cause an appeal to automatically kick out. Make sure you use the correct form and that it's completed correctly and that you have attached relevant information.
Information such as EOB's or explanation of benefits, are critical in getting your appeal processed. While it is true that they have the EOB on file and you've provided the information on the form for them find it, all insurance companies will still require this one piece of vital information.
Any other information that backs up your appeal is critical as well. Copies of your policy and/or copies of your medical records will go a long ways in proving your point.
It goes without saying that you want to keep copies of everything you submit in your appeal. This way if you have to re-submit due to a denial you only have to make copies instead of recreating the whole appeal.
While gathering all of this information seems like a lot of work, especially when the insurance company has all the information on file, it's well worth the effort in the long run. You don't want to give them any more reason to reject your appeal so do the homework and follow their instructions by submitting a complete appeal.
Thursday, January 17, 2013
Wednesday, January 2, 2013
It's All In The Detail
Any time you're billed for something that you believe you shouldn't be, details are of the utmost importance. They can mean the difference between paying and not paying.
When you call, get the name and number of the person you spoke with. Ask if they issue reference numbers and write that down. If you're asking if something was paid by the insurance, get check amounts and numbers. If they state they received a claim, ask what was on it and write that down as well. You can never collect too many details. You never know when they may come in handy.
The same principal applies if you're appealing or disputing a claim. The first detail is whether or not your insurance company will consider your "dispute" an actual appeal, reconsideration request or an inquiry. While this may be seen as a mundane splitting of terms, it's actually critical information. Some insurance companies will only let you appeal two or three times but yet they'll let you send in an inquiry or reconsideration multiple times. We all know insurance companies rarely get it right the first time and multiple disputes have to be sent in in most cases.
Some things can be resolved by phone calls. However other times it's best to send in a dispute in writing. When you're sending in a written dispute you want to be concise and to the point. If a processor sees a long winded appeal with too many details, they'll most likely process it as a duplicate because they don't want to take the time to read it! They're cramped on time, remember?
While you need to get to the point in writing your appeal, you still need to include enough details to make it easy to understand. I always say you need to draw them a picture and assume they can't add. While that may seem comical, it's effective and you can include just enough details to get your point across.
Tools like bullet lists are handy to show the history of your claims history. You can detail out what has happened on the claim without having to say over and over again, "Then I called.... ". It's all there in order.
Another detail tool is an equation. If you're only supposed to pay 20% and you're being billed for 30% do the math for them right there on your written dispute. When things are calculated out in an appeal, the success rate goes a little higher just because the processor is not having to do the math and double check your request.
As they say, the devil is in the details. Gather as many details as you can and respond with only what you need!
When you call, get the name and number of the person you spoke with. Ask if they issue reference numbers and write that down. If you're asking if something was paid by the insurance, get check amounts and numbers. If they state they received a claim, ask what was on it and write that down as well. You can never collect too many details. You never know when they may come in handy.
The same principal applies if you're appealing or disputing a claim. The first detail is whether or not your insurance company will consider your "dispute" an actual appeal, reconsideration request or an inquiry. While this may be seen as a mundane splitting of terms, it's actually critical information. Some insurance companies will only let you appeal two or three times but yet they'll let you send in an inquiry or reconsideration multiple times. We all know insurance companies rarely get it right the first time and multiple disputes have to be sent in in most cases.
Some things can be resolved by phone calls. However other times it's best to send in a dispute in writing. When you're sending in a written dispute you want to be concise and to the point. If a processor sees a long winded appeal with too many details, they'll most likely process it as a duplicate because they don't want to take the time to read it! They're cramped on time, remember?
While you need to get to the point in writing your appeal, you still need to include enough details to make it easy to understand. I always say you need to draw them a picture and assume they can't add. While that may seem comical, it's effective and you can include just enough details to get your point across.
Tools like bullet lists are handy to show the history of your claims history. You can detail out what has happened on the claim without having to say over and over again, "Then I called.... ". It's all there in order.
Another detail tool is an equation. If you're only supposed to pay 20% and you're being billed for 30% do the math for them right there on your written dispute. When things are calculated out in an appeal, the success rate goes a little higher just because the processor is not having to do the math and double check your request.
As they say, the devil is in the details. Gather as many details as you can and respond with only what you need!
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