Learning the Rules of Appeals

Step One: Establish a review process for "outlier payments." Outlier payments are those payments which are significantly lower than the anticipated reimbursement for that type of claim. The review process should involve assessment of these outliers for the potential inaccurate application by the payer of downcoding, modifier reduction or bunding edits.

Step Two: Appeal outlier payments. The type of appeal letter depends on the reason for the suspected downcoding or modifier/bundling reduction, such as medical necessity or the ubiquitous "internal coding guideline." If the coding decision appears to be driven by medical necessity considerations, you may want to outline the clinical justification for the coding utilized by your organization. However, many payer coding decisions do not involve medical necessity and can be appealed by demanding a manual review by a certified coder. A certified coder will likely be in the best position to explain how the payer coding edits affect reimbursement and would possibly provide input regarding treatment variables which might justify overriding a coding edit to allow additional benefits.

Step Three: Persist until payer complies with good information. Payers do not readily provide detailed information about coding edits and many coding appeals will require a Level II or higher appeal.  High-level appeal reviewers are likely aware of disclosure laws which may require detailed explanations of how coding edits apply to specific claim scenarios.  Therefore, make sure that a Level II appeal draws attention to any specific disclosure request which was not responded to in previous efforts.  Consider language such as the following if the Level I appeal response failed to provide specifically requested information:

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