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How to Prepare for a Medical Billing Appeal

As a medical billing professional, there are a few things you should know before you begin an appeal. Preparing an appeal to correct an incorrectly processed claim is an art. You have to know enough about the details of the claim and the individual quirks of the payer to find a workable, timely solution.

In the case of an appeal, the burden of proof is on the provider to show why the claim has not processed correctly. How you approach an appeal has a big impact on how smoothly and quickly the process goes.

An appeal that is based on the contract and that clearly defines how the claim should have processed usually results in a reprocessed claim, especially if the contract has a prompt pay clause. If the payer failed to process the claim according to the contract and the error resulted in a delay of prompt payment, the payer may have to pay interest.

Know who you’re dealing with

The primary contact between a provider and a payer is the provider representative. In most cases, however, your first point of contract is actually with the provider relations department, otherwise known as provider services. If you are responsible for claim follow-up, prepare to spend a lot of time on the phone with these individuals.

Provider services

The people who work in provider services can check to see whether a claim was received, can usually provide a processing time, and can sometimes facilitate correcting an improperly processed claim. When a claim processing is not in compliance with the payer contract, often the remedy is a simple phone call.

If the payer has loaded the contract correctly, the provider services representative can identify the problem — usually with coaching from you — and send the claim back to processing with instructions regarding what needs to be done.

If your contract was not loaded correctly, then calls to provider services for resolution are useless because these representatives rely on the information loaded into their systems, and they have no way to verify contract specifics. In this case, you need to turn to your provider representative.

Provider representative

If your contract wasn’t loaded correctly, you address the problem through your provider representative, who is the individual responsible for making sure that the contract between the payer and the provider has been correctly loaded into the payer claims processing system(s).

In this situation, you need to contact the provider representative to let him know that the claims are not paying as agreed. Normally, you can get the name of the provider representative from the provider relations department or the payer website.

Your provider representative generally tries to assist with contract or claims issues, particularly issues that may cause several claims to pay incorrectly for the same reason — which is usually a contract problem. If you have a contract with the insurance company, disputes should be easily resolved. Without a contract, things can get difficult, so be sure to have all of your is dotted and ts crossed.

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