416 ||||||||||| APPENDIXES CPT copyright 2015 American Medical Association. All rights reserved. Appendix B I. Know How and Why to Appeal Inappropriate Health Plan Claim Denials It is estimated that physicians are losing billions of dollars in revenue each year by not appealing inappropri- ate claim denials. There are many reasons why physician practices do not appeal denied claims the most common is that they believe appealing claims will create an increased administrative burden on the practice. However, not appealing denied or partially paid claims can be quite costly to your practice and can often result in decreased revenue. Since health plans have introduced claims editing software into their claims processing systems, they have generated an increased number of inappropriate claim denials and reductions in payment. An effective way for your practice to combat these erroneous payment reductions and denials is to be diligent in submitting appeals. Why Appeal? When your practice increases its appeals for wrongfully underpaid or denied claims, the health plan may cor- rect its claims editing software and processes. This, in turn, may result in improved claim processes and appro- priate payment to your practice for the provision of health care services. The 12 steps under How to Simplify the Claim Auditing and Appeals Processes below simplify the claim auditing and appeals processes and can help to reduce your administrative burden. These processes make it easy for your practice to identify and appeal health plan claim denials when the health plan misapplies the American Medical Association Current Procedural Terminology (CPT®) codes, guidelines, and conventions or the health plan’s contracted policies. When a physician performs a procedure or service and then reports according to CPT codes, guidelines, and conventions, the health plan should recognize the physician work involved in providing this patient care. To ensure that your work is recognized, your practice should identify all inappropriate claim denials and commu- nicate with the appropriate health plan representatives through each plan’s claim appeals processes. What Is Lost When Your Practice Does Not Appeal? When your practice does not audit and appeal inappropriately paid or denied health plan claims, you may lose revenue. You also may lose the opportunity to recover overhead expenses by not implementing a claims management process. This process is your practice’s internal designated work flow for accurately preparing, submitting, and collecting on claims. When you challenge inappropriate claim payments, you demonstrate that your practice has made an effort to correct the plan’s inaccuracy. This could lead to a positive change in the health plan’s business practices. Appealing claims that are inappropriately denied by health plans can make a difference in your practice by reducing future denials. For additional information, there are 2 easy ways to contact the American Academy of Pediatrics (AAP) Private Payer Advocacy Advisory Committee. 1. Go to www.aap.org/en-us/professional-resources/practice-support/financing-and-payment/Pages/Private- Payer-Advocacy.aspx (AAP members only). 2. Contact the AAP Coding Hotline at aapcodinghotline@aap.org. How to Simplify the Claim Auditing and Appeals Processes 1. Know the health plan’s claim appeals processes before you need to submit a claim appeal. Understanding these processes will allow you to acquire the health plan information (eg, supporting documentation, health plan language) required to prepare a claim appeal. 2. Know where to locate the following health plan policies and, if possible, include them in the health plan contract: Claim adjudication procedures (ie, definitions of complete or clean claims and medical necessity) Rates and payment methodology, including a comprehensive fee schedule Claim appeals processes 3. Document, document, document. The supporting documentation of a claim submitted to a health plan must substantiate the performance of a service by the treating physician or health care professional. If a service is not documented, it didn’t happen in the eyes of the health plan, and the claim may not be paid. 4. Review and monitor all claims before submitting them to the health plan to ensure that you are filing complete and accurate claims. One way to avoid a claim denial is to correctly code the original claim. Implement a checks-and-balances system between physicians and the coding and billing professionals in your practice to determine whether claims are being coded appropriately. 5. Maintain a coding reference sheet in your practice with a list of commonly used International Classification of Diseases, 10th Revision, Clinical Modification codes and CPT codes, as well as any other commonly reported codes on the standard claim form.
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