Medicare claim denials have become a reality for most O&P facilities, but preparation and education can help business owners effectively and efficiently appeal denials in order to focus on patient care, according to David McGill, JD, vice president of Compliance and Reimbursement for Össur, and Linda Collins, director of Market Access for Össur. The pair provided tips and suggestions for successful appeals during a recent webinar.
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Appeals take time; start planning early
Because the Medicare claims system is so backed-up, if a practitioner receives a denial today, “it is very likely that you will not be seeing an ALJ [administrative law judge] until 2019 or 2020,” McGill said.
The reimbursement landscape has changed, and the increase in denials has led to an increase in appeals and a much longer payment cycle. As such, McGill said it is critically important to work through the process in as efficient a way as possible.
Winning an appeal actually starts long before a denial is received, according to McGill, which is why he advises approaching each claim under the assumption it will be denied. Although this may sound counterintuitive, it is a critically important mindset needed to work through the five steps of a successful appeal, he said.
Know your information
When writing an appeal, the first step is to identify the basis for the denial. This is not always clear; sometimes the reason can be “buried” in the denial, McGill said. However, only two possible substantive grounds exist for a denial: either the denial is contesting the claim’s records about the medical necessity of the device, or the denial states the device is experimental or investigational.
Although other grounds for denials exist — eg, the insured was not covered by the policy at the time of the delivery — McGill classifies these as “non-substantive.”
“Every substantive appeal you [write] will be addressing either A, ‘I think it is medically necessary,’ or B, ‘I do not think it is experimental or investigational,’” McGill said. “In some instances, insurance companies deny on both grounds simultaneously.”
The experimental and investigational grounds typically are usually only used in reference to private insurance coverage for prosthetic devices, he added.
Collins noted Medicaid denials do not apply here.
“There are situations where you might be dealing with a Medicaid program and they are denying just because … they have an archaic claims system that cannot handle the way [health] care is delivered today,” she said. “We can appeal those situations and ask them to … manually override the [denial].”
Step two is to locate and organize the information needed to rebut the denial.
“It is mechanical, and it is laborious and a bit boring, but investing the time and energy to do this is absolutely critical,” McGill said. “You cannot construct arguments without the evidence on hand to support them.”
One document essential to have on hand is the letter of medical necessity.
“It is a key exhibit in any appeal,” he said. Although not officially part of the supplier’s medical record, a well-constructed letter of medical necessity lays out all of the key facts in a comprehensive and persuasive fashion that makes it easy for a review to understand the patient’s situation.
Get to the point
Step three may seem clear, but it often gets lost in a sea of information, according to McGill. In this step, it is critical to start with the core issue.
McGill said the beginning of an appeal should get straight to the point: “The insurer denied this claim because X. The insurer is wrong because X.”
He also recommended following the “90-second rule” when forming an appeal.
“Within 90 seconds of the person picking up the piece of paper, they should understand what you are asking for and why,” McGill said.
In fact, this could be shortened to 30 seconds, or even 15 seconds, for an appeal, McGill said. Rather than forming a full-blown argument up front, a summary of key points is more appropriate.
McGill encouraged anyone writing an appeal to consider every aspect of the document, including its aesthetics. Writers can bold or italicize the most important points in the body of the appeal. When dealing with exhibits, underline all information that is most relevant for the reviewer to see.
“This all goes back to the concept that [the appeal writer’s job] is to make this easy for the reader,” he said.
Similarly, step four is to write clearly. For example, instead of the phrase “variable cadence,” McGill recommends using the phrase “different speeds.” A reader without an O&P education should be able to understand the appeal.
“You can either communicate using lots of jargon, which is confusing and may end up making your point less clear, or you can say the same thing but … talk like a normal human being,” McGill said.
McGill’s last suggestion was to use footnotes. Footnotes will keep the document clean and prevent it from becoming clogged with references.
“Every exhibit you cite in every appeal you write should only be referenced by footnotes. Do not put parenthetical [references] after every sentence,” he said. “When you do that, you make it hard for the reader.”
Last, McGill reminded listeners that they have a choice: Wait until a denial is received and then react; or, act first.
“You are going to act or react. Appeals are inherently reactive, but the work of a claim is inherently active,” McGill said. “If you are active up front [and plan for the claim to be denied], you will have everything ready up front. You are going to have all the elements right there. You have already done it all.” – by Amanda Alexander
McGill D, et al. Steps to Successful Appeals. Össur webinar; April 23, 2015.
Disclosures: Collins and McGill report no relevant financial disclosures.