Guest post: Seven strategies to build an effective appeal process

by Denise Wilson, RN, MS, RRT, and Karla Hiravi, RN, BSN

Facility appeal writers must craft piles of appeals, with virtually no time to investigate the accuracy of payer denials. However, understanding the appeal process is crucial.

Engaging a physician advisor can bring the knowledge and experience of a physician to the revenue cycle arena. A physician advisor can assist with appeal work, especially clinical validation, by serving as a peer liaison to educate physicians on proper documentation that can help prevent denials and pursue appeals. Along with the expertise of revenue recovery specialists, physician advisors are invaluable to the appeal process.

A recent report by the Office of Inspector General revealed that Medicare Advantage organizations overturned 75% of their own prior-authorization and claim denials from 2014 to 2016. During that period, beneficiaries and providers appealed only 1% of denials to the first level of appeal—a statistic that suggests significant revenue loss. As healthcare organizations move toward value-based reimbursement, understanding and addressing the impact of denials on revenue integrity is essential.

1. Engage a physician advisor to support the appeal process and promote revenue integrity.
2. Investigate the denial rationale—don’t take the denial reason at face value.
3. Encourage ongoing communication and education.
4. Ensure coders are up to date on all coding resources.
5. Promote collaboration between coders and clinical documentation improvement staff on combination issues.
6. Share denial and appeal issues with all team members for education and process improvement.
7. Communicate with medical staff regarding pertinent documentation trends that affect coding. Inconsistent or incomplete documentation impacts both billing and quality of care.

Editor’s Note: This article originally appeared in JustCoding. Wilson is the vice president at Denial Research Group’s AppealMasters and Hiravi serves as director of clinical appeal services for AppealMasters. She holds a BSN from the University of Pittsburgh, Johnstown. Contact them at Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.