Q&A: After the third level appeal

Q: I was wondering if anyone had experience with denials from commercial payers that goes beyond the third level of appeals. We are getting response letters that state “completion of a level 3 dispute exhausts internal administrative rights.” What are other hospital systems doing with this response?

A: There are generally limited options after a third level commercial denial. One recommendation, however, is to rate your denials to see which were incorrectly denied and then pursue a legal escalation process to get the maximum return on investment.

Payers generally have an appeals policy. Look to your revenue cycle department or denials management department and see if they can direct you to this policy.

You can also try calling the insurance company and requesting to speak with a manager to discuss the situation. Keep in mind that as part of the contracting services, there is usually a customer service representative that a payment variance manager can contact and discuss the case with after all appeal processes have been completed.

Keep in mind that if the denials are not coming directly from the payer, but from a contractor for the payer, you may have multiple levels of appeal for DRG downgrade denials. Following your denials, you might have the option to have a peer-to-peer review call. You can take up to five levels and the peer-to-peer as a level six.

Editor’s note: This question and answer were adapted from a thread on the ACDIS Forum. To learn more about participating on the Forum, click here.