Experts Offer Tips for Provider Appeal of Denied Medical Claims

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Knowing payer policies and regulatory requirements is critical to appealing denials.
Knowing payer policies and regulatory requirements is critical to appealing denials.

HealthDay News — Knowing payer policies and regulatory requirements is critical to appealing denials, according to an article published in Medical Economics.

Michael Strong, a bill review technical specialist at SFM Mutual Insurance Co. in Bloomington, Minn., and Tammy Tipton, owner of Appeal Solutions Inc. in Oklahoma City, suggest several tips to ease the appeal process.

First, Strong says, look at the remark codes and address those specific edits, including documentation of lab or operative reports. Ask for exceptions to payer policies in the cases of atypical patient presentation or pediatric patients, Tipton advises. 

In addition, she says to cite regulatory information in the appeal letter, including Medicare Local Coverage Determinations and National Coverage Determinations, the Affordable Care Act and its expanded access to external reviews, and the Employee Retirement Income Security Act, which allows providers with authorization to appeal on a patient's behalf.

"Being smarter than your payers is the key to successful denial management," Strong said in the article.

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