Q&A: Tips for appealing denied claims

Q. What strategies should hospitals follow for deciding whether to appeal denied claims and submitting appeal letters?

A. Consider the following tips for appealing denied claims:

• Appeal even if you think your organization made a mistake.
• Involve the physician when appropriate (e.g., when addressing medical necessity denials).
• Know the deadline for appealing a denial. An appeal can be overturned simply for missing the deadline, even if it would have otherwise been successful. Some contracts have deadlines for appealing. Use certified mail for payers who have a track record of not receiving appeals or for high-dollar claims.
• Understand contract terms.

The appeal letter should:

• List relevant bullet points (e.g., why you disagree with the denial).
• Use clinical indicators when appropriate.

A physician advisor should sign clinical appeals letters.

In general, use staff members that have good writing and critical-thinking skills. The appeal letter should be concise, clear, and make a logical, easy-to-follow argument in support of the appeal. Attach only pertinent documentation. Don’t attached an entire medical record and expect the payer to weed through the record.

For more information, see The Contemporary Guide to Health Information Management.

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