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Helpful Tips for Appealing a Medical Claim Denial

September 6, 2018

Claim Denials

Analysis by Change Healthcare  in 2017 found that out of the approximately $3 trillion in medical claims that were submitted in 2016, nearly $262 billion were denied initially. While it’s best to prevent denials as much as possible, when you do have denials you can’t afford to let them slip through the cracks or your practice will lose a significant amount of revenue. Here are a few helpful tips you can use to successfully appealing a medical claim denial to ensure you’re getting paid for the services you provided.

Tip #1 – Submit an Appeal Letter to the Payer

Some practices make the mistake of sending a balance bill along with an explanation of benefits (EOB) to the payer instead of actually providing an appeal letter. With an appeal letter, you’re able to spell out what you want to have reviewed, such as coding denials or fees. While it takes a little more time to put the request in writing, it can make a huge difference in whether your appeal is successful.

Tip #2 – Make Sure You’ve Corrected the Claim 

Before you send the appeal to the payer, make sure that you’ve corrected the claim if the original was incorrect. If you send in an incorrect claim again, the appeal will not change the results. The claim’s CPT coding, documentation, diagnoses, and EOB should all be checked for accuracy. Look closely at any modifiers used to ensure they’ve been applied appropriately. Adding a modifier to a claim simply to get it paid could result in accusations of abuse or fraud. After your review of the claim, making any changes and add documentation as needed before you resubmit. When you do find coding issues as you’re dealing with denials, make a note of the problem and review it with all of your coding staff to prevent the same mistake from occurring again. 

Tip #3 – Only Code What You Can Support with Medical Documentation 

One of the most important rules of billing and coding is that if you can’t document it, then you cannot report it. No matter what you’re billing, review the notes to ensure that all procedures that were reported were actually performed. For example, when surgeries are billed, it’s very common to code from the list of procedures that were noted at the beginning of the notes. However, things may have changed during the operation, and a careful look at the notes may reveal other reportable procedures that were performed and not mentioned in the note summary. 

Related Article:  Four Simple Steps to Reduce Medical Claim Denials

It’s also important to avoid relying on the recommended coding from the physician. Review the documentation provided to ensure you’re reporting the right codes. In some cases, the record may need to be amended by the physician to better reflect that patient’s condition and the nature of the services provided. 

Tip #4 – Be Sure to Check for Simple Mistakes 

In many cases, claims denials are the result of simple mistakes like claims not being completed correctly, illegible claims, missing filing deadlines, insufficient, non-existent, or incorrect documentation, or failing to obtain a pre-authorization. It’s crucial to check for these mistakes before a claim is submitted, but when you’re filing an appeal, it’s essential to check for simple errors again to avoid the claim being denied a second time. Eliminating any small mistakes will ensure your appeal is successful and you get paid faster. 

Tip #5 – Follow Up and Then Consider Getting the Patient Involved 

Follow up with the payer after you submit an appeal to ensure it’s being processed. If you have a problem getting resolution, you may want to consider getting the patient involved. Many patients don’t realize that an unpaid balance can be passed to them, and patients are often willing to call their insurance carrier to see what they’re able to do to get the claim paid. Your office or the patient can request an external review through the state insurance department if the appeal is denied. 

Preventing Future Denials 

Although a large percentage of claims denials are recoverable, the appeals effort comes with an administrative price tag, so it’s important to take measures to prevent future denials. Staying on top of changes, providing staff and providers with training, and doing routine claims denial audits are all ways you can avoid denials in the future. Outsourcing your billing and coding may be another option to consider if you want to reduce denials, increase the success of appeals, and improve practice revenue.  

M-Scribe can work with your practice to prevent denials and deal with appeals when needed. Contact us today at 770-666-0470 or email me at to learn more about how we can help your practice reduce denials and improve practice revenue. 


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