The Clinician’s How-To Guide to Insurance Claim Appeals

March 11, 2024

Working in healthcare means dealing with rejected insurance claims and insurance claim appeals. These appeals can be frustrating and time-consuming. This is true whether you have experience in billing or are new to the field.  

As you strive to provide the best care for your patients, understanding the appeal insurance claim process is key. It also ensures you receive proper payment for your services.

Use this step-by-step guide to evaluate your rejected claim. You’ll also learn how to successfully appeal an insurance denial to help increase your chances of approval.

Tips to avoid an insurance appeal claim

The following are tips and best practices to help guide you through the insurance billing process:

Keep meticulous records for future reference

While mistakes happen, there are some things you can do to prevent errors and in turn, claim denials. Keeping meticulous records can help prevent claim denials and if the need arises, help facilitate a smoother appeals process.

According to Amy Plano, a dietitian and expert in the field of insurance reimbursement:

“It’s important to take careful notes with each insurance company interaction, noting things like who they spoke to, date and time, and getting any applicable reference numbers.”

When checking a patient’s coverage, it’s important to keep track of the reference numbers for each call made to insurance companies. This way, if an insurance representative makes a mistake and provides misreported benefits on your verification call, this reference number helps you build a compelling case during the appeals process.

Collaborating with billing and administrative staff

Some practitioners hire professional billing assistants to help them with insurance claims and appeals. If you have anyone else on your team, clear communication can help prevent insurance claim denials or navigate the appeal process more effectively. Setting clear standards for note-taking and record-keeping makes documents more accurate and complete before submission. With clear notes, your team can reduce denials because of missing or incorrect information.

Additionally, collaboration between you and your administrative team can uncover potential issues early in the process, allowing for timely corrections. 

Stay updated on insurance regulations and policies

The health insurance industry constantly updates policies and regulations. Staying updated ensures that you’re aware of any changes or specific requirements set by insurance providers.

Amy Plano explains:

“Providers must stay consistently informed on each plan they are billing by regularly checking the provider’s online portal for any changes impacting their services.”

This knowledge helps you prepare and submit claims accurately, reducing the chances of denials from non-compliance.

Using online resources and insurance claims support groups

In discussing the challenges of insurance billing, Amy Plano points out that “there are not many comprehensive resources available to dietitians that teach the reimbursement process. Finding a course or mentor is a great place to start. Information online may be helpful but isn’t always accurate. So, being aware of the potential inaccuracies is important.”

Additionally, participating in support groups allows you to share experiences and learn from others who have faced similar challenges. Knowledge sharing can enhance the accuracy of claim submissions while reducing denials and the need to appeal insurance claims.

Step-by-step guide to appeal insurance claims

Here’s how you can successfully appeal an insurance denial to help increase your chances of approval:

Review the denial

The first step in appealing an insurance denial involves a complete review of the denial itself. In this review, look for specific denial reason codes or explanations, ranging from coding errors to missing information.

A view of claims statuses for insurance claims appeals in the Practice Better portal.
View the status of your claims, including paid and rejected claims, in Practice Better through the Claim.MD insurance integration.

During this review you will verify the accuracy of the denial by cross-referencing the insurer’s decision with the patient’s medical records. Use this time to ensure that all information is accurate, complete, and compliant with the insurer’s policies.

This first step helps you build a compelling appeal that addresses the denial’s specific issues. This way, you can increase your chance of a successful appeal.

Gather necessary information for your insurance claim appeal

The second step to appeal an insurance claim involves carefully collecting necessary information. Amy Plano suggests including the following information in each note:

Information needed for your insurance claim appeal

  • Patient demographics: Name, date of birth, contact information, insurance ID, and policy information. The patient’s name and DOB must be at the bottom of every note page. 
  • Initial/Follow-up assessment: Detailed information about the patient’s medical history, health status, dietary habits, allergies, medications, and relevant lab results. Has it changed or remained the same from previous visits? 
  • Treatment plan: Specific recommendations, including meal plans, portion sizes, nutrient goals, and lifestyle interventions. What was provided during the session? After the session?
  • Follow-up notes: Regular updates on the patient’s progress toward their, including any changes in dietary habits, weight, symptoms, and adherence to the treatment plan.
  • Follow-up appointments: Schedule and document follow-up appointments to monitor the patient’s progress and assess what will be assessed at these visits. 
  • Billing information: Documentation of services provided, including CPT codes, diagnosis codes (ICD-10), and any other relevant billing codes required for insurance reimbursement. Also, state the patient’s and provider’s location when the service was provided.

By gathering all of the supporting documents and aligning them with the insurer’s rules and policies , you can strengthen your appeal. 

How to write an insurance appeal letter

In your insurance appeal letter it’s important to directly address the denial reason stated by the insurance company. For example, you may see the denial code A456 which suggests that the nutrition services provided were not deemed medically necessary based on the insurance company’s evaluation.

In your letter, you will provide this specific denial code and explain why your services were medically necessary and aligned with the coverage outlined in the policy. You’ll also want to provide documentation like medical records, physician notes, or relevant test results that show the medical necessity of your services.

Look for insurance appeal letter templates online that can help you craft an effective appeal for a denied claim.

Insurance appeal letters: an important tool for challenging claim denials

An effective insurance appeal letter can be a powerful tool in the appeal process. Let’s explore how to write an insurance appeal letter with each important component in detail.

Clear identification of the patient

Begin your appeal letter by clearly identifying the patient involved. Include details such as the patient’s full name, date of birth, and insurance identification information.

Detailed description of the medical necessity

Provide a detailed and compelling explanation of the medical necessity of the services rendered. Explain how these services directly contribute to the patient’s health and well-being.

For example, you may say, “The prescribed dietary interventions, including tailored meal plans and nutrient goals, are vital for managing [patient’s name] diabetes and preventing further health complications.”

Supporting documentation

Include relevant supporting documentation to justify your claims. For example, you may attach medical records, test results, physician notes, and other information that reinforces the medical necessity of your services.

Clear and concise language

Craft your appeal letter using clear and concise language. Avoid unnecessary information and present your case in a direct manner.

For example, you could state, “I am writing to appeal the denial of nutrition services for [patient’s name] due to concerns about medical necessity. I believe that the prescribed interventions are essential for managing their [specific health condition].”

Addressing the denial reason

Specifically address the denial reason provided by the insurance company. Clarify any misunderstandings, correct errors, or provide additional information related to the denial reason.

For example: “The denial reason code A456 was cited, indicating concerns about the medical necessity of the nutrition services. I would like to address this by highlighting the chronic nature of [patient’s name]’s condition and the preventive nature of the prescribed dietary interventions.”

Providing additional context and relevant information

Offer additional context and relevant details that may not have been apparent in the initial claim submission. Explain any unique circumstances or considerations that support the necessity of the nutrition services.

For example, you may explain that a patient has a family history of a chronic condition and that genetic factors influence their health needs.

Using professional and respectful language

You may be familiar with the saying “You catch more flies with honey than with vinegar,” meaning that being kind and polite is more effective than being harsh or critical.

You may be frustrated at the claim denial, and that’s okay, but maintaining a tone of professionalism and respect can increase your chance of success.

For example: “I appreciate your attention to this matter and kindly request a thorough reconsideration of the denied claim. If there are any additional details required or if further clarification is needed, I am readily available to provide them.”

Steps to submitting the insurance claim appeal

To submit your appeal letter, send it through the appropriate channels and follow the insurance company’s guidelines for appeals. This may involve mailing a physical letter or submitting the appeal through an online portal.

It’s also important to submit your letter in a timely manner. Insurance companies often provide a window of time within which you can submit an appeal after receiving a denial letter.

Amy Plano explains:

“Each insurance company has a statute of limitations on how far from the date of service the provider can submit a claim. For most commercial claims, this time frame is 90 days from the actual date of the appointment. If you submit a claim outside this time frame, the insurance company is not required to pay the provider.”

The same goes for insurance appeals. The time frame for submitting an insurance appeal letter can range from 30 to 180 days. However, it’s essential to refer to the information provided by the specific insurance company.

Remember to keep a copy of the appeal letter and all supporting documents for your records.

Overcoming common challenges in insurance claim appeals

The insurance appeals process can present the following challenges:

Dealing with repeated denials

If you’re facing repeated denials, a thorough review of each denial reason will help you move forward. Identifying patterns or common issues can help you address root causes and adjust claim submissions accordingly

Handling complex cases

In handling complex cases, focus on providing comprehensive documentation that clearly outlines the medical necessity of the services rendered. This may involve collaborating with other healthcare professionals to ensure that all relevant information is presented cohesively.

Managing the emotional toll on clinicians

Amy Plano explains, “Most providers don’t have any baseline knowledge for billing insurance. So, they are essentially accepting insurance with little to no knowledge and then getting frustrated when things don’t turn out as they want to.”

However, the frustration associated with denied claims can be alleviated through peer support and staying informed about the appeals process.

The takeaway

It’s important to understand insurance claim appeals to protect your practice’s finances and advocate for your patients.

During the steep learning curve, find a reliable billing partner. That might be software like Practice Better, or a knowledgeable billing expert, or both.

By staying informed and advocating for your patients, you can focus on providing quality healthcare while securing fair compensation for your services.

Practice Better is the complete practice management platform for health and wellness professionals. Streamline your practice and begin your 14-day free trial today.

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