Providers commit to fighting denied claims but call process 'inefficient'

Thursday, March 17, 2011

YARMOUTH, Maine - When it comes to denied claims, home medical equipment providers aren't taking "No" for an answer, according to the results of a recent HME NewsPoll.

Seventy-four percent of providers who took the poll reported that they appeal denied claims more than 50% of the time.

"We are appealing our denials all of the way out because we feel we are giving the auditors exactly what they are asking for and they are still denying us," said Lane Newsome, CFO of Triad Respiratory Solutions in Winston-Salem, N.C.

NewsPoll results were based on 104 responses.

Most of the time, providers are right to stand up to CMS and its contractors. Fifty-one percent of providers reported that they're able to reverse denied claims 51% of the time.

"We have an appeal success rate of 95%," said Heather Moore, billing manager at Medicor LLC in Salt Lake City.

The key to success, Moore says: "Knowing what to appeal and having the ammunition to support your reasoning."

Another tip from a successful appealer of denied claims: "I attribute our wins to getting the physician to write their own letter regarding the reason why the claim is denied, thus giving more credence to the appeal."

Providers are more hesitant, however, to appeal a denied claim all the way to the administrative law judge level. An overwhelming majority of providers reported that they take this step less than 25% of the time.

But when providers do look to the ALJ for relief, they're, again, often successful.

"I have gone to the judge level in a few cases, and I have one that will be done (in March)," said Rebecca Tiseo, president of American Home Medical Equipment in Las Vegas. "I have won the other two and feel confident that this one will work out, as well."

Numerous providers who took the poll expressed frustration that they--and CMS--have to go through this timely and expensive process when the claim could have been paid on first passing.

"Talk about inefficiencies," said one provider who took the poll. "We project that the cost to Medicare for our product is doubled by the time the claim is reversed at the ALJ level."