Sometimes the only way for a hospital to get paid is to file an appeal. Payers sometimes refuse to reconsider wrongful denials without a formal letter of appeal. Certain types of denial reasons, such as technical denials, can’t be addressed through peer-to-peer review and must go through the written appeals process.
Filing an appeal can be a laborious process. First, you must correctly identify the reason for the denial. This is often more complicated than it sounds, as the information on the EOB or denial letter may be incomplete or misleading; such cases may require multiple phone calls to the payer to confirm the denial reason. Second, you must determine a plan of attack. Identify the relevant statute, regulation, or contractual clause that shows why the payer’s denial reason is incorrect.
Next, you must gather all supporting information. This may include medical records as well as any legal or contractual citations, system documentation, and payer communication. After that, you must write the appeal in a way that clearly explains your argument and gives the payer a good reason to overturn their denials. Once you’ve gotten your appeal out the door, you must follow up with the payer to ensure that they’re actually received it and monitor the outcome.
This is a lot of work for hospital teams that are often wearing multiple hats and juggling multiple responsibilities. That’s where HLS comes in. We have extensive knowledge of appeal requirements and procedures for all payers and all denial reasons, which allows us to optimize and expedite every step of the appeals process.
To learn more about how HLS uses our experience with the appeals process to increase revenue for hospitals, click here to read some of our case studies