Q&A: Building an appeals program

Q: What are the recommended elements of a Medicare appeals program?

A: A successful appeals program centers on a clinical appeals team having a thorough understanding of health insurance provider contracts, state and federal laws and regulations, and facility processes that have a direct and indirect impact on denials. This education provides the appeals team with critical tools needed to write effective appeals. The appeals team must have a handle on the revenue cycle administrative and clinical processes that generate the production of a claim for each patient encounter. Understanding how each department and its respective processes impact the revenue cycle is also critical for the appeals team members. Accurate identification of denial type, reason, and source lays the groundwork for successful root cause analysis.

A revenue cycle flowchart can prove valuable, as it is a high-level overview of key areas and departments. However, it may leave the impression facility administrative and clinical processes are simple and streamlined. The appeal team must understand that under each area of a revenue cycle flowchart there are facility-specific processes that have the potential to become the denial source. In addition,understand that each patient brings variability to each encounter that may also contribute to generating a denial.

For more information, see The Contemporary Guide to Patient Financial Services.