Denial Appeals Process In Medical Billing in Westpoint

An appeal is submitted to the insurance companies when the insurance company disagrees and denies the services provided by the healthcare providers and withholds reimbursement of the services.

Cause of the denials:

Most of the denials can be avoided when you use your PMS (practice management system) and the clearing house more effectively with accurate information. On average, 50% of the denials would be related to eligibility issues, patient demographic information, and the benefits of the patient policy, which are considered front-end issues that can be arrested by your clearing house and the PMS. Providentially, most denials can be recovered, but the involved process typically requires a lot of manpower. So, iMagnum Healthcare Solutions Inc. will help you out by providing extensive support to help you focus your time on the right track of growing your business.

Things to remember when we submit an appeal:

* Timely submissions

Every insurance company expects the appeals to be submitted within the time limit provided by them. Traditionally, Medicare allows 120 days from the date of denial to initiate the initial redetermination; however, every state's Medicaid program and commercial insurance companies have their own protocols. Your appeal will be denied, and the insurance company will uphold the original denial decision unless you submit it within the appeal time limit.

* How strong is your appeal letter and its content?

The content of the documentation always speaks to the appeal reviewer on behalf of the payer. So, it should be sustainable, precise, and have exactly what insurance is looking for. The cover letter should explain to the payer the reason for the appeal and how your documents support your claims to get the reimbursement. Also, the cover letter must specify the attention, your contact information, and the denied claim information. In most cases, your appeals can be processed and paid when you are specific on the denial reason and facilitate the handling by attaching the documentation, such as medical records, progress notes, and denial EOB.

Be Aware: When a claim can be appealed?

A denied claim by the insurance company cannot be appealed. There should be research on the reason for the appeal.

• Verify if our services are covered under the patient plan before appealing the claim.
• Verify if the benefits of the services are exhausted.
• Know your provider's network status with the insurance.
• Verify if we are within the time limit to send.
• Verify if we have all the necessary documents to appeal the claims.

Submitting to the insurances:

Now that we are all set to send the appeals to the insurance company, There are insurances that would provide where to submit the appeal document in the EOBs. If it is unavailable, we need to make sure that we are getting the mailing address, fax number, or email from the insurance company.

How iMagnum can help you in the appeal process?

As the above process is quite time-consuming, the iMagnum team can help you appeal the claims for your practice by following the below process.

• iMagnum will collect the necessary information, such as the fax number, mailing address, website to be uploaded, or email address, from the payer to submit the appeals to the insurance.
• Most importantly, there are insurance companies that might use their own cover sheet and will not accept the practice’s cover sheet. This will be verified by our team with the insurance, and the same cover sheet will be received from the payer.
• As we have everything now available to be sent to the payer, we will prepare the cover sheet with appropriate comments based on the denial received, attach the medical records accessed from the PMS and the denial EOB, and send it to the insurance.
• We sent the appeal to the insurance company now! That it? No, the iMagnum team will follow up on the appeal submitted to the insurance and make sure that the insurance has received it.
• After the confirmation, we will get the decision on the appeal, whether it is a denial or payment.
• If it is denied, we need to verify the decision and make sure we are submitting the next level of appeal.

So, levels of appeals?

iMagnum will shed some light on the appeals for you. There are basically 5 levels of Medicare appeals; perhaps Medicare and commercial insurance would accept only 2 levels of appeals from the billing support team.