RCM tip of the day: Be ready to appeal claim denials

Kelly Gooch - Print  | 

For success in appealing claim denials, healthcare providers should know their payer contracts and the patient's coverage-benefit plan design, said  Lyman Sornberger, vice president of client development at Charles J. Hilton and Associates law firm.

"Do not assume that a denial is correct," he told Becker's Hospital Review. "If the health plan refuses to pay for treatment, providers should consider appealing if the clinical documentation supports: medical necessity; or if the treatment isn't a covered benefit, but the provider is confident that there are clinical reasons for an exception; and/or if the treatment is deemed by the insurance company to be experimental or investigational."

Mr. Sornberger said healthcare providers can respond to insurance denials through an informal appeal, which "is simply a call to the insurance that issued the denial," or through a more complex formal appeal.

"Be prepared with medical record, signed documents, physician support, language in the contract and/or benefit comments. Document all conversations with dates, times and contact," he said.

 If you would like to share your RCM best practices, please email Kelly Gooch at kgooch@beckershealthcare.com to be featured in the "RCM tip of the day" series.   



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