In today’s complex healthcare landscape, appeals have become a routine and essential part of securing reimbursement for claims. With payers frequently denying coverage for a variety of reasons, a well-crafted appeal strategy is no longer optional; it’s vital to the financial health of any medical provider. While each payer may have its own unique appeal procedures, the core principles of an effective appeal approach can be applied universally across payers and device types.
The first step in an effective appeal strategy is accurately identifying the reason for the claim denial. A common misstep in the process is focusing solely on arguing medical necessity without addressing the specific denial rationale. For example, if a claim is denied due to a “same or similar” device already being provided, and the appeal only emphasizes the need for the device without explaining the justification for its replacement, the likelihood of a successful outcome is significantly reduced.
Claim denials related to medical necessity are often vague, offering little clarity about which specific coverage criteria were not met. These situations require a critical, objective review. Start by researching the payer’s medical policy for the device in question. Absent published payer policies, providers should refer to Medicare’s policy language. Use these criteria as a checklist to evaluate the treating practitioner’s medical records, identifying which elements are supported and which are lacking. Where deficiencies exist, an addendum to those medical records may be warranted prior to appeal to improve the likelihood of success.
Once you’ve confirmed that the medical records and supporting documentation meet the coverage criteria for the claim, the next step is to determine whether a cover letter would enhance the appeal. This decision may depend on the specific payer and the level of appeal being pursued. A cover letter can be particularly useful when aspects of the records and/or documentation are vague or unclear. The letter can also be used to draw attention to each of the required elements of coverage within the submitted documentation. Most importantly, the letter should focus on the specific reason for the denial and present clear, evidence-based justification for why the denial is inappropriate—ultimately supporting a favorable appeal outcome.
Another often-overlooked aspect of a successful appeal strategy is the documentation that should not be included. Only submit materials that are required by the payer, relevant to the claim in question, and that clearly support the appeal argument. Any additional documentation that is not required or is not relevant to the claim should be left out. For example, in Medicare appeals, submitting a dispensing order is no longer required as of 2020—provided that a valid Standard Written Order or Written Order Prior to Delivery is included. Being selective and intentional with your documentation helps maintain focus on the core argument and increases the likelihood of a favorable outcome.
The final step in an effective appeal strategy is a thorough review of the appeal packet before submission. Many appeal errors are clerical and entirely preventable. Begin by confirming that all required documentation is included, complete, and valid. Are any date requirements satisfied? For documents that require a signature, are the signatures valid and authorized by the appropriate individual (whether from a physician, clinician, or patient)? Are all coverage and coding requirements satisfied? This final review is your opportunity to catch and correct any remaining issues, helping to ensure the appeal is submitted in its strongest possible form.
A well-defined appeal strategy can greatly enhance the likelihood of a successful claim outcome. By establishing a consistent, universal approach that applies across payers and device types, providers can ensure each appeal is both structured and compelling. Let the documentation and narrative within the appeal clearly convey the patient’s story and justify the reimbursement being sought.
Lesleigh Sisson, CFo, CFm, and Curt Bertram, CPO, are part of the leadership team at O&P Insight. They have a combined 64 years of experience in O&P administration, clinical services, and operational management. You can contact them at lesleigh@oandpinsight.com or curt@oandpinsight.com. Michelle Wullstein, CPCO, has been in the Medicare profession for over 18 years and is an AAPC-certified professional compliance officer who provides O&P-specific medical policy, billing, documentation, and HIPAA compliance support to internal teams and clients. While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors.
