Audits: Appeal early, appeal often

Q. Is it better for me to wait to file my appeal and group my appeals together?
Friday, October 25, 2013

A. Many suppliers consider waiting until the end of the timeline for appealing a claim so they can group together as many claims for that patient as possible, viewing this as a savings in manpower and employee expense.  While writing only one appeal may be a savings in one part of your workload, putting off getting a favorable appeal decision costs much more than it saves.

Suppliers often call me with similar stories.They received an audit for January’s rental claim, February and March claims were paid, and now claims from April onward are being denied. The reason for the on-going denials is because of the original audit denial. The only way to stop the denial from rolling in is to overturn the audit finding. The quicker you get a favorable appeal decision, the quicker you can obtain a payable status on the rental claims and end the denial/appeal cycle. Waiting to appeal the original audit only prolongs the process, costing you more money in the end.

Another benefit in this case is the ability to use the reopening process. Once you obtain a favorable decision on the audited claim, you can reopen (instead of appealing to redetermination) any later rental claims that were automatically denied without individual audit.  The reopening process is easier and quicker than a redetermination appeal—meaning less employee time and better cash flow.

The number one goal in a ZPIC audit is to decrease the error rate. By allowing denials to stack until the end of the filing period, you are prolonging the actual ZPIC audit. The best—and quickest—way to get off a ZPIC pre-payment audit is by having a low error rate. For ZPIC audits there should only be one approach to appeals: appeal early and appeal often!

Jillian Longo is a consultant with Harrington Management Group, LLC. Reach her at or 888-833-3478.



I just read this and thought what I have writen below may be some better advice in appealling a claim!!

Appealing often may Not completely be the best idea!!  If a Provider's payment is held up for the first month of a claim; filing subsequent claims will follow with denials.  It would be better to refrain from billing any subsequent month's claims until the patient file is completely corrected and queeried by the carrier. 

The system is set up so that each claim is adjudicated on it's own merit.  That means if you win the first appeal it does NOT give a pass on the subsequent claims once submitted.  Therefore the best solution is to file the appeal on the first month's claim held for payment by the carrier and NOT submit subsequent month's claims until the patient's file is queeried by the carrier to pay the billing code on the specific diagnosis codes.  

Here is an example of the chronolgy why this may work better.  If month one is denied and the appeal process begins for discussion purposes let's say it takes 6 months to get the queery established on the claim by the carrier.  In the mean time you bill months 2 through 6.  Now months 2 through 6 could each take six months on appeal maybe less maybe more.  That would not get you paid on month 6 until month 12.  If you don't bill months 2 through 6 and wait until the first month clears the queery than you can get paid, for discussion purposes, the full 6 months by month 7, since you won't need to wait for an appeal process to conclude for the susequent claims months 2 through 6.  You get paid more sooner!  If everyone just keeps billing for claims they know won't get paid it will continue to gridlock and clog a system already designed to move at a snails pace!!

Keep in mind to be observant as not to exceede any statute of limitations for submitting subsequent bills!!

You may find this your better solution.