How to File a Medical Billing Appeal with the Payer - dummies

How to File a Medical Billing Appeal with the Payer

In medical billing, you will need to file an appeal if something goes haywire during the claims process and your provider doesn’t get paid or receive the amount contracted. Another point you may have to appeal is violation of prompt pay statutes.

Prompt pay statutes define how long a payer has to pay a claim after having received it. The prompt pay statutes are different in each state, so make sure you know the statute that applies to your provider. If the payer doesn’t pay within the legislated time-frame, the statute usually obligates additional payment of interest, which accrues on each claim. Often, this accrual is per day.

If the payer delays or stalls payment, interest is due. Because the interest amount is usually small, providers often overlook it. Don’t. Enforcing the prompt payment rules keeps payers accountable. Plus, if the situation were reversed, don’t think for one minute that the payer(s) would not enforce the interest penalty.

When you file an appeal, make sure you base the appeal on facts. If a contract exists between payer and provider, you need to quote the verbiage of the contract in the appeal. If the payer is refusing to honor a negotiated agreement, you refer to the agreement.

If the payer still refuses to settle the matter to your satisfaction, then you may need to take the issue to the state insurance commissioner, an attorney who specializes in this area of the law, or the Department of Labor.

Remember the two golden rules of appealing a claim, and you’ll be just fine in the coding world: First, keep impeccable documentation of every interaction you have with a payer. The paper trail you create might serve you well later when questions arise about the claims you process. And second, always, always keep your cool, on the phone and in writing. Think Dragnet style — just the facts, ma’am!

Each state has a Department of Insurance that is responsible for making sure that insurance companies operating within the state follow the state’s insurance laws. These laws are in place to protect citizens. Examples of problems that can get an insurance company in trouble include selling policies to individuals but not paying claims. You can locate the Department of Insurance for each state through that state’s website.