Appeal Letters
Physicians lose billions upon billions of dollars annually due to coding errors, denied or delayed payments, typos, submission errors, omissions and you name it. Surgical coding errors alone, for example, cost physicians nearly $6 billion every year.
We all know that people make mistakes. Typos, submission errors and omissions can be easily corrected to ensure that payment will be made by the medical insurance companies. With time, coding errors can also be minimized by using good coding software and by studying good coding newsletters. Denied payments should also be paid, 98% of the time, by using effective appeal letters, filing complaints with federal and state agencies, and more.
Unfortunately, one of the greatest reasons why healthcare providers are not collecting the money they should from medical insurance companies is because they simply won't fight for it.
Insurance companies rate healthcare providers and billing companies on a scale of 1 to 5. One is the lowest, usually symbolized by a "hot dog," which means that the medical insurance companies can pretty much have their way with the provider or biller. Five is the highest ranking, usually symbolized by a "bull dog," which means the medical insurance companies will pay quickly, with very few rejections. The difference between these rankings has to do with the degree to which a provider or biller is willing to fight for what is legally and ethically owed them.
Sending powerful appeal letters, along with letters that cite federal and state insurance laws, as well as filing complaints with state and federal agencies will move you up the "don't mess with us" scale faster than you'd think. It will take time and effort, but it definitely pays huge dividends.
The most common appeal letters you will need to send out are letters that demand payment for procedures denied because of what CPT calls "bundled" procedures. Sometimes, bundled procedures are never allowed to be "unbundled" while at times they are allowed to be "unbundled." Those procedures that are allowed to be unbundled must be paid when the proper modifier is used.
Why the appeal letters then?
Insurance companies have all their claims reviewed by a software program called the NCCI editing system. NCCI automatically denies ALL bundled procedures, including those that are allowed to be unbundled with the use of proper modifiers. Medical insurance companies are mandated under HIPAA law to manually review, and also pay, those claims that have modifiers properly appended.
Do medical insurance companies manually review these claims? In a perfect world, yes; however, the more you fight for payment the less likely insurance companies will deny these claims. You'll be amazed at how quickly medical insurance companies will begin to do their job when you start to send letters and issue complaints with state and federal agencies.
The following is a copy of our modifier 24 review letter. Feel free to use it as often as you'd like. Simply put your letterhead on top and your name below, and it's all yours.
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Ashdown & Associates
Certified Medical Reimbursement Specialists
276 East 272nd Street Euclid, OH 44132 216-732-3003
March 15, 2006
RE: E/M service with Modifier 24
Dear Sir or Madam:
Our company is well aware of the CPT guidelines regarding the proper use of modifier 24.
Because we are extremely well aware of the proper use of modifier 24, we ONLY use modifier 24 to LEGALLY and ETHICALLY override the NCCI edits when this particular E/M service, though within a global period, is for a DIFFERENT diagnosis. As you know, CPT and NCCI allow a billable office visit "within a global period when the patient is seen for a diagnosis OTHER than the diagnosis for which the patient previously had surgery."
There are times when a patient will present to John S. Doe, MD with a problem/diagnosis, within a global period, OTHER than or DIFFERENT from the problem/diagnosis for which the patient was previously treated. It is not unusual that this very same office visit will be used to discuss surgery for this new diagnosis. In this case, we will use modifier 57 along with modifier 24. In short, we will ONLY use modifiers to LEGALLY and ETHICALLY override NCCI edits when these exceptional cases warrant their use.
We expect your company to either adjust your Claims Check system to comply with CPT's guideline with regard to modifier 24 or review manually any claim that is kicked out of your system. We also expect your company to make note of our company's competency with regard to CPT guidelines so that we do not have to spend untold wasted hours telling you that we are well aware of CPT and NCCI guidelines.
We expect prompt payment for this claim. Please feel free to contact our office with any questions.
Respectfully,
Kevin N. Ashdown,
Ashdown & Associates
After we too were swindled out of thousands upon tens of thousands of dollars for multiple medical management software packages and billing franchises, we found that ONLY ONE billing system will do EXACTLY what it is has been designed to do. Click here to find out more
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