Planning Strategies
Fight for Payment of Valid Claims
You can win through the appeal process.

Medical and even mainstream publications are filled with stories about the barriers doctors face in getting paid in today's healthcare environment. Precertification, managed care and tight filing deadlines are some of the hurdles physicians must finesse when seeking reimbursement. And, if one detail is missed, the effort and attention you expended in the exam room goes for naught in the business office.

Health plans, capitated medical groups and independent provider associations deny thousands of specialist claims a year. They know most practices don't have the time, insurance industry experience and legal expertise to investigate the basis, or lack thereof, of claim denials.

DENIED, DENIED, DENIED

Payers use powerful computer systems to bundle, downcode and reject physician claims, often with little explanation to the doctors affected. In part, that's because health plans consider their rules and systems proprietary knowledge.

Jeffrey J. Denning in his article, How to Challenge Medicare Payments, cited a government report that as many as 90% of the decisions made by Medicare about whether services are medically necessary are made by overburdened workers with only high school educations and no medical training or background.

Most practices ignore what's perhaps the most effective action they can take for securing payment on a denied medical claim -- filing an appeal. A large percentage of the practices that I've consulted with said they didn't have a systematic approach to filing appeals or didn't have the time to do so. That's no answer when large sums of your hard-earned money are at stake.

ILLUSTRATION: ANTHONY CERICOLA

USING THE APPEAL PROCESS

Always file an appeal when a health plan reduces or denies the payment that should have been paid to you based on the services rendered.

Many practices have a difficult time trying to determine whether they have legitimate appeals to submit or just bad debt that should be adjusted off the books. Do you know what percentage of your aging accounts reflect payments denied because your office failed to meet the health plan's re-filing policy for correcting errors or adding additional information to meet the clean claim criteria? Most health plans won't pay you if you violate this contract provision.

Does your practice know what percentage of your aging accounts is tied to claims that should be appealed because the health plan downcoded you or underreimbursed a procedure?

WHEN YOU'RE RIGHT, FIGHT

You need to have the mindset that it's the health plan's burden to prove that your claims have been processed correctly. Many claim denials are overturned after just a single appeal letter. Persistence is often the key to overturning denied claims. Health plans overturn as many denials during the second and third appeals as on the first appeal.

Successful practices are now using a structured approach to collect appealable dollars. At many practices, staff members are assigned a specific number of hours each week to focus on appeals. Others now outsource the appeal process to companies specializing in this niche area. And some practices have purchased software products designed to automate the appeal filing process.

Physicians are finally realizing the economic impact of not collecting the dollars that should be theirs. As much as 10% of your total accounts receivable could fall into the appeal process category. Remember, an ounce of appeal can result in a pound of payment.

Dr. Gable is chief executive officer of Dynamic Health Connections, Inc., in Lake Forest, Calif., which provides specialized consulting expertise for subspecialty physician groups, managed care organizations and other medical organizations. You can reach him at dhc38@aol.com.