Start preparing at intake

Thursday, March 24, 2011

A. Claim denials are inevitable but most denials can be appealed. Unfortunately the supplier bears the burden of collecting documentation from the referral source. Therefore it is critically important that suppliers understand coverage criteria for equipment being provided. Then they must possess the finesse of obtaining the documentation from the physician. Suppliers know the importance of medical documentation but the process of obtaining it can be  frustrating and often futile. 

The best way to prepare for an appeal is to develop a process that incorporates verification of compliance into every step from intake to delivery through post-delivery follow up.

First, involve the patient in the document collection process by having the patient contact his or her physician to honor your request for the documentation.

Next, intake staff must understand the local coverage determinations and be able to determine that the patient's chart contains all of the required elements. Ideally, the intake process will include reviewing medical records from the physician prior to delivery or prior to billing. Illegible portions of the medical record are excluded from Medicare's review, so ask the physician's office to provide translation on portions of the medical record that are illegible. Third, understand the denial by calling the carrier for a verbal detailed explanation. 

Last, complete the appropriate appeal form. If using a letter to request the appeal, specifically state that the letter is an appeal of a claim denial and include all required criteria listed on the appeal form.  

Important: An appeal that doesn't include a written narrative may be insufficient. The narrative should include the reasons you disagree with the denial and clearly reference the portions of the documentation that support medical necessity. The narrative should lead the reader to the conclusion that the documentation does in fact support the medical necessity.

Remember, begin to prepare during intake.

Cheryl Ward is CEO of Agape Medical Management. She can be reached at 951-680-1640 or