Strong medical claim denial appeal letters can combat healthcare provider denials
A recent survey confirms what many of us already know: Claim denials in healthcare are increasing. However, what you might not know is this: More than a third of providers (38%) say payers deny 10% or more of their claims. That’s a significant impact on your medical practice’s bottom line. And while promoting clean claims is always ideal, let’s face it: Denials are inevitable, and they happen for a variety of reasons. What you do after they occur is critical.
We’re talking about appeals. Rather than accepting payer denials as the status quo, you can make your case for payment by asking the payer to reconsider its decision. Your most valuable asset? A strong appeal letter.
Tackling healthcare provider denials
Not sure what to include in an appeal letter? Here are six simple tips to craft an appeal letter that can help you fight claim denials in healthcare…and increase your chances of winning.
1. Avoid generic salutations. If possible, address the letter to a specific individual rather than ‘To whom it may concern.’ Using a specific individual’s name commands attention which is exactly what you want.
2. Start with a brief introduction. Thank the individual for the opportunity to submit the appeal for reconsideration of payment. Then make it easy for the payer to understand the context of the denial and the purpose of your letter. Do this by stating the patient’s name and date of birth, insurance information, claim or reference number, date of claim submission, date of denial, and the payer’s reason for the denial (including the payer-specific claim adjustment reason code).
3. Provide detailed evidence regarding why you feel the payer should overturn the denial. If possible, use the payer’s own definition of medical necessity per its website or payer policy manual. Then include summaries of progress notes describing treatment history and outcomes, test results, clinical guidelines, or expert opinions that support why the service is medically necessary. Multiple pieces of evidence make it difficult for the payer to justify the denial.
4. Address the payer’s concerns. List each concern separately (as outlined in the explanation of benefits) followed by a brief description of what you’ve done to address those concerns. Again, it’s about making it difficult for the payer to defend its original decision.
5. Ask the payer to reconsider in light of your argument. Reiterate your main arguments, particularly the medical necessity of the treatment, and ask the payer to reconsider its denial with the patient’s best interests in mind.
6. Provide your contact information. Ensure the payer knows how to reach you if it has questions or needs additional information. Include an email address and phone number, if possible.
Leveraging a strategic approach
Though it may be tempting to send an appeal letter for every denial, this isn’t necessarily the best approach. Why? You’ve got limited time and resources (especially considering ongoing healthcare staffing shortages). That means you need to prioritize claim denials in healthcare based on insurance payer, amount, age of bill, or other business rules to ensure maximum benefits. It’s important for your revenue cycle team and/or outsource revenue cycle vendor to identify your medical practice-specific appeal strategy and the insurance denial appeal letter template you’ll use.
Additional strategies
In addition to knowing what to include in an appeal letter, be sure to maintain a respectful and nonconfrontational tone and focus on the mutual goal of providing high-quality patient care with the best possible patient outcomes. Maintaining a patient-focused theme throughout the medical claim denials letter makes it difficult for the payer to ignore the impact of the denial on the patient.
If you do attach documents to the letter (e.g., the explanation of benefits, medical records, or articles from peer-reviewed journals), be sure to provide a bulleted list of what you’ve attached so the payer doesn’t overlook anything. In addition, consider incorporating your medical practice brand throughout the medical claim denials appeal letter to make it stand out. A professionally designed appeal letter with your medical practice logo and colors can definitely work in your favor.
One caveat? Some payers may circumvent the entire appeal letter process altogether by requiring you to use their specific form or protocol to address healthcare provider denials. When that’s the case, do what they require because any deviation from that won’t produce your desired results.
Looking ahead
A medical claim denials appeal letter is just one part of an overall strategy to improve cashflow and promote financial sustainability. Proactive denial management is always a first choice, but when denials happen (which they will), having an insurance denial appeal letter template that you can easily adapt for each scenario saves times and increases the likelihood of successful appeals. Use this insurance denial appeal letter template in concert with denial analytics and advanced automated tools to reduce claim denials in healthcare. Learn how edgeMED can help.
