What to Say during the Medical Billing Appeal Process

During the appeal process in medical billing, it’s important to know what to say to get your desired result. You want to keep to the facts. If a contract exists, refer to the language of the contract.

If the problem is a bundling issue (one or more of the CPT codes on the claim are considered incidental or inclusive to another), then describe the extra work — be sure to include the extra time involved — and why this time investment was necessary. In addition, let the payer know what payment you are expecting or what payment agreement will be acceptable to close the claim.

Keep your emotions in check in these situations. The old saying that you can catch more flies with honey than vinegar totally applies here. Try to keep your comments positive and use appropriate, formal language on the phone and in written communications. Some effective phrases to use during appeals include:

  • Our contract obligates CPT 5555 to allow $1,234.” Say this if you didn’t receive the amount you should have or the payer disputes the amount owed.

  • “This service was authorized prior to the date of service by ABC, and this is the authorization number: 1234.” Say this when you want the claim to be reprocessed because it was denied for lack of precertification.

  • “We are aware of the edits; however, this procedure should not bundle because it required access through a separate incision.” This provides an explanation for your request for extra reimbursement.

  • “I can send a written appeal. Can you provide a fax number and address please?” This information ensures that the claim gets to the right place.

  • “What do I need to do to facilitate this issue?” or “Who should I speak with about this problem?” These questions alert the person on the other end that you plan to do what needs to be done to resolve the claim.

Avoid using phrases such as “It’s not fair” or “We didn’t know the surgery wasn’t covered.” Here’s a newsflash: The payer doesn’t care. Payers are running a business, and disputes regarding payment are just that — business — which is what they should be to you, too. So follow the payer’s lead and keep things professional.

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