Timely appeals help preserve rights of healthcare providers.
The signed agreements between healthcare providers and managed care plans regulate the terms of the parties’ business relationship. These terms, often detailed in the payer’s provider manual, seem simple: “Follow our rules and you will be paid.” That of course is not always what transpires, and many claims are denied improperly. What happens when the contracted provider follows the terms of the agreement but is not reimbursed by the health plan?
This prospect highlights one important point of awareness: Providers must file timely denied claim appeals through completion of the appeals process. Indeed, when a claim is denied, a provider should promptly file all appeals to preserve its rights, thereby eliminating often-unnecessary procedural disputes in the event litigation ensues.
Here are 5 suggestions to help ensure your post-appeal rights are preserved:
First, review your contract and provider manual. Understand the permissible timeframes for first and second level appeals. Start by reviewing the signed contract, and always keep copies of the executed agreement readily available. Don’t forget to carefully read the applicable provider manual in addition to your contract. These administrative guides may be retrieved from a health plan’s website or obtained from the payer’s network representative. Provider manuals may be updated on a yearly basis, but appeal timeframes should not change that frequently, as minimum appeal timeframes are often set by law.
Second, use reminder systems to meet appeal deadlines. Because first level and second level appeals are subject to filing timeframes, the earlier appeal’s deadline must be met before the subsequent level will be considered on its merits. The same goes for those plans requiring “reconsiderations” to be submitted before filing of formal appeals. Note that “reconsiderations” are essentially first level appeals with required pre-printed forms as coversheets.
Third, develop a tracking and reporting system. A simple database or spreadsheet deployed to track deadlines and report appeal outcomes is a necessity. Not only will a well-designed spreadsheet help you avoid untimely appeals, it will also allow you to identify denial categories and ascertain aggregate lost revenue within those buckets. Recurring denial categories also point to problems that may be easily corrected. For this reason, recurring improper denials should be brought to the attention of the payer in advance of any litigation.
Fourth, assign responsibility. Staff assigned with the responsibility of ensuring that deadlines are met must know the varying appeal windows among health plans. Even if necessary to hastily beat an approaching deadline, it may be sufficient to re-write and file an earlier appeal – repeating earlier arguments – to preserve your rights to recovery.
Fifth, use outside resources to help manage this process. Never step over a quarter to pick up a dime. Use experienced resources to pursue post-exhaustion remedies such as pre-litigation settlements and filing of judicial and arbitral claims when needed. LegalHealth is available to assist in this endeavor.
Remember: Follow the best practice of appealing all claims until appeal rights are exhausted. If this sounds like a lot of work, you are right. The importance is tantamount to your bottom line.
Gustavo Matheus is a member of Anderson & Quinn, LLC, in Rockville, Maryland, representing hospitals, medical practices, nursing homes, and outpatient centers with exceptional legal and denials management services. www.andersonquinn.com.
