Learn How to Write Effective
Appeal Letters When Your Claims
Have Been Denied:
Important Strategies for Revenue
Cycle Integrity
LaDonna Waugh, M.D., J.D., F.A.C.S.
Director of Appeals Management
Accretive Health, Inc.
November 9, 2011
SLIDE 1
The Appeal Letter
•
•
Appealing adverse decisions made by payors or
private contractors on behalf of commercial
payors, Medicaid, and Medicare is predicated
primarily on effective written communication.
This communication may be used in legal
proceedings, and the appeals process should be
considered a legal process.
©2011 RAC MONITOR LLC
SLIDE 2
The Appeal Letter
•
Effective appeal letter writing is very
important and if properly framed is one of the
best tools in recovery of revenue for the
hospital and in securing benefits for the
beneficiary patient.
©2011 RAC MONITOR LLC
SLIDE 3
The Appeal Letter
•
•
Crafting an effective legal argument is
therefore crucial to constructing an appeal
letter, irrespective of payor or appeal
processes.
Letters written to achieve a legal outcome
have some specific features that are not
often seen in other types of business
correspondence.
©2011 RAC MONITOR LLC
SLIDE 4
The First Step
•
•
The first thing a legal argument should do is
identify the issue.
The issue is the single thing that is presently
in controversy. In an appeal letter, the issue
is often related to the payment of money: the
insured patient’s benefit.
©2011 RAC MONITOR LLC
SLIDE 5
WHAT is the controversy?
•
•
•
Did the payor disagree with the DRG
designation?
Did the payor make a partial payment
because they valued the service differently
than the hospital billed it or agreed to pay
based on certain specified criteria?
Did the payor deny payment because there
was no documentation to support that the
care that was billed was medically necessary?
©2011 RAC MONITOR LLC
SLIDE 6
WHAT is the controversy?
•
•
•
Did the payor disagree with the DRG
designation? CODING
Did the payor make a partial payment
because they valued the service differently
than the hospital billed it or agreed to pay
based on certain specified criteria? LEGAL
Did the payor deny payment because there
was no documentation to support the care
that was billed was medically necessary?
DOCUMENTATION
©2011 RAC MONITOR LLC
SLIDE 7
Identify the issue in the first
sentence.
•
“Acme Insurance Company denied the claim
for Benjamin Beneficiary covering care given
by Happy Hospital on these dates.”
©2011 RAC MONITOR LLC
SLIDE 8
The reader then knows what the letter is about,
and if the reader is a judge, he or she wants
this information right up front. If the
judge/arbitrator/state reviewer has to look for
the issue because it is not presented
immediately at the beginning of the letter, he
or she is already predisposed to ruling against
the letter-writer. This phenomenon has been
studied and described in legal journals!
©2011 RAC MONITOR LLC
SLIDE 9
The Second Step
•
Next, state the contention, or the position, of
the letter writer. Identify what side of the
argument this letter will take.
©2011 RAC MONITOR LLC
SLIDE 10
WHAT is our position?
•
•
•
Does the hospital believe that they should be
allowed to rebill for a corrected DRG?
Does the hospital disagree with the payor’s
findings that authorization was not obtained
or that criteria for a particular level of care
was not met?
Does the hospital believe that the care given
is consistent with what was billed and what
was medically necessary?
©2011 RAC MONITOR LLC
SLIDE 11
The second sentence identifies the
argument of the letter writer.
•
•
•
“Happy Hospital is of the opinion that the care
provided to Benjamin Beneficiary was covered
by Acme Insurance Company, and the claim
should be paid as submitted.”
“Happy Hospital contends that authorization
was properly obtained prior to rendering of
[inpatient] services.”
“Happy Hospital believes that the care given
to Benjamin Beneficiary was reasonable and
necessary under the circumstances, and the
findings of Acme Insurance Company should
be reversed.”
©2011 RAC MONITOR LLC
SLIDE 12
The Third Step
•
Finally, identify the desired outcome, and
be specific about what the letter aims to
accomplish.
©2011 RAC MONITOR LLC
SLIDE 13
WHAT is the desired remedy?
•
•
•
A remedy is a proposed solution to solve the
controversy – it describes the desired
outcome the letter advocates.
Should the payor reimburse a DRG based
upon support and documentation provided by
the hospital where the coding is supported by
clinical remarks and actions of the treating
physicians?
Should the payor approve payment of the
level of care or services provided?
©2011 RAC MONITOR LLC
SLIDE 14
The final sentence of the first
paragraph should identify what is at
stake in the controversy.
•
“Happy Hospital requests a redetermination
by the Acme Insurance Company and full
payment on the claim submitted for the care
of Benjamin Beneficiary.”
©2011 RAC MONITOR LLC
SLIDE 15
Here’s how it might look beyond the
initial request (at the second level of
appeal):
•
“Happy Hospital requests a reconsideration
by Independent Insurance Auditor of Acme
Insurance Company’s decision, and requests
a finding in favor of Benjamin Beneficiary for
care provided by Happy Hospital.”
©2011 RAC MONITOR LLC
SLIDE 16
The Body of the Appeal
•
FACTS
•
Applicable Rule(s)
•
Evidence to support position and Analysis of
the situation
©2011 RAC MONITOR LLC
SLIDE 17
Facts
•
•
•
Report objective information about the patient
using an unbiased and balanced approach.
Emphasize abnormalities and findings of concern.
Include normal findings to bolster credibility.
Acknowledge the facts that do not aid your
argument without emphasizing them; this
suggests you are confident that they do not
affect your recommended outcome, and also that
your side of the argument can be supported in
spite of them.
©2011 RAC MONITOR LLC
SLIDE 18
WHICH facts are important?
•
•
•
•
•
•
•
•
Patient identification and initial presentation
Characteristics of the chief complaint (For
example, with chest pain: How long did the
chest pain last? Where was it located? What
associated symptoms were present? Did it
occur at rest?)
Past Medical History and Past Surgical History
Medications
Physical examination findings
Results of laboratory and imaging tests
Stabilizing measures, and initial treatment
Clinical progress and clinical outcome(s)
©2011 RAC MONITOR LLC
SLIDE 19
Use of Bullet Points may be most
effective with Coding/DRG appeals
•
•
Listing facts that support coding submitted with the
original bill can be very effective.
For example, if you are denied payment for acute
renal failure, unspecified, ICD-9 code 584.9, you
might list the reasons the chart supports that
documentation as bullet points – was there a bump in
creatinine greater than 0.2? Were other diagnosis
related criteria met (such as RIFLE criteria for renal
failure)? Use the clinical/objective findings to support
the contention. The reviewer/payor must then
successfully refute each point asserted to validly deny
the claim.
©2011 RAC MONITOR LLC
SLIDE 20
Report Facts in a Narrative Form
for Medical Necessity Appeals
•
“Benjamin Beneficiary is a very old man who
presented to Happy Hospital with complaints of
chest pain of forty minutes duration . . .”
•
“His past medical history is significant for . . .”
•
“He received nitropaste without relief . . .”
•
“His initial troponin was elevated at . . .”
•
“EKG changes suggested ischemia, so he was
taken for urgent cardiac catheterization.”
©2011 RAC MONITOR LLC
SLIDE 21
Applicable Rules
•
For Coding/DRG denials, the rules that govern
the appeal will likely be coding and billing
criteria for a particular ICD code. The letter
should rely on the bullet points outlining the
facts to demonstrate that the condition was
present at admission, or ruled in during the
hospital stay, and stress that criteria for
billing a certain diagnosis were indeed
present. If review of the facts reveals that
the ICD diagnosis code should have been
different than that billed, the letter should
include a request to rebill with the new
code(s). Many payors will accept a rebill
request.
©2011 RAC MONITOR LLC
SLIDE 22
Applicable Rules
•
•
For commercial payors and Medicaid, the
rules that govern the appeal will be the
criteria by which the payor reimburses for a
specific diagnosis or procedure. A showing
that the criteria were present to support a
certain level of care will be required in
crafting an effective argument.
In the alternative, following the “rules” with
certain commercial payors, Medicaid, and
Managed Medicare may require a showing
that proper authorization was indeed secured
prior to rendering the services in question.
©2011 RAC MONITOR LLC
SLIDE 23
Applicable Rules
•
With Medicare, often an author can include
statements and directives based upon actual
regulations, like Chapter 1 of the Medicare
Benefits Policy Manual which outlines the way
in which Medicare determines inpatient status
and covered inpatient benefits.
©2011 RAC MONITOR LLC
SLIDE 24
Applicable Rules
•
•
For example, for a short stay, it would be
appropriate to point out that an inpatient
level of care decision is independent of length
of stay.
Medicare guidelines also make much of the
importance of deference to the admitting
physician’s designation of inpatient, as the
physician has the advantage of seeing the
patient clinically, and is tasked with
determining what adverse risks are faced by
any particular patient.
©2011 RAC MONITOR LLC
SLIDE 25
CAUTION
•
•
It is important to ensure that what the
letter is requesting does not violate or go
against what the regulation requires.
It is also critical that the letter is not
asking for payment for something that
does not meet payor criteria.
©2011 RAC MONITOR LLC
SLIDE 26
•
Applying the rules and criteria appropriately
preserves the letter writer’s credibility. Over
the longterm, a judge or arbitrator will be
able to say, “Amy Appealer writes clear,
concise letters and does not advocate for
frivolous appeals. Her requests are made in
the right situations, and for the right
reasons.”
©2011 RAC MONITOR LLC
SLIDE 27
•
Credibility wins appeals!
©2011 RAC MONITOR LLC
SLIDE 28
Evidence and Analysis
•
•
Find supporting medical literature to support
the events told by the facts.
A minimum of 3-4 supporting articles is
recommended to bolster a legal argument.
Google Scholar is a great legal resource,
because you can search by phrases, for
example, “adverse outcome after syncope in
the elderly.”
©2011 RAC MONITOR LLC
SLIDE 29
Evidence and Analysis
•
•
•
Most large hospital systems have a medical
librarian who is happy to find supporting
literature for almost any topic.
Keep a personal file with references that
support admissions for common diagnoses
such as chest pain, so that they are at hand
when needed.
Update references that are more than 10
years old.
©2011 RAC MONITOR LLC
SLIDE 30
“Marry” the facts to the literature.
•
•
If you have a 45 year old who has serum glucose
of 503 when she presents with acute renal
insufficiency, a medical literature reference that
discusses adverse outcomes in elderly diabetics
does not apply to your set of facts.
Conversely, literature that supports a 15%
mortality rate from hyperosmolar complications
in diabetics with blood sugars over 450 with
acute medical problems “marries” the facts
(sugar of 503) to the literature findings regarding
adverse outcome (15% mortality irrespective of
age).
©2011 RAC MONITOR LLC
SLIDE 31
The Conclusion
•
•
The conclusion of the letter revisits the
contention and the desired outcome
supported by the body of the letter.
This should be a brief paragraph of one to
three sentences. It is ideal if the conclusion
can be a single sentence summation that
reminds the reader what is at stake.
©2011 RAC MONITOR LLC
SLIDE 32
The Direct Approach is Best
•
“For the reasons listed above, Happy Hospital
respectfully requests reversal of Acme
Insurance Company’s decision to deny
payment of Benjamin Beneficiary’s claim.
©2011 RAC MONITOR LLC
SLIDE 33
A few other points . . .
•
•
Use plain language, avoiding legalese or
medicalese wherever possible.
Use active voice as much as possible. Avoid
passive voice and phrasing. (Think Star Trek
– “…to boldly go …” – the classic example of
bad language in passive voice!)
©2011 RAC MONITOR LLC
SLIDE 34
A few other points . . .
•
•
Letter-writers should use the buddy system to
review letters. (Two heads are better than
one.)
Spellcheck. Enough said. Many newer
versions of Word actually do simple grammar
checks with the spellcheck, and will alert you
to that inadvertent extra space or missing
comma.
©2011 RAC MONITOR LLC
SLIDE 35
A few other points . . .
•
Finally, after spellchecking, try this trick:
Read your letter out loud to yourself. Your
ear will catch irregularities that the eye does
not see, and you will catch grammatical
mistakes and hear awkward phrasing.
©2011 RAC MONITOR LLC
SLIDE 36
And one more thing . . .
•
•
Quality over quantity
Be direct, concise, and avoid redundancy and
embellishment. The conclusion should mirror
the initial paragraph without restating it
verbatim, and should be the only duplicated
language. An eight page denial letter is too
long, unless you must justify each day of the
stay with a separate argument. Most
appeals arguments can be made in two or
three pages.
©2011 RAC MONITOR LLC
SLIDE 37
THANK YOU FOR
ATTENDING
©2011 RAC MONITOR LLC
SLIDE 38