Q&A: Next steps after a payer upholds a denial

Q. If my hospital submits an appeal to a payer and the payer upholds the denial, what next steps can we consider?

A. If your appeal is unsuccessful and the denial is upheld, the denials team should evaluate the strength of the facility’s position. If you determine your position is well supported, do not hesitate to file a second-level appeal. Throughout the RAC process, it was widely identified by providers that the majority of level 1 appeals were denied. In fact, in many cases, the same was true for the level 2 appeal. It wasn’t until level 3, or the Administrative Law Judge level, was reached that providers started noticing success.

For managed care and PPO payers, it is important to understand their specific appeal process. Some payers allow second-level appeals, but beyond that a more formal process must be followed. There are payers who only allow one appeal. In any case, your first appeal must be clear and complete, containing all information necessary to support your appeal.

For more information, see Medicare Compliance Essentials Training Compendium.

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