When Appeals Are Not Enough in Medical Billing


If you are as enthusiastic about medical billing and reimbursement, it can be vexing when we receive a denial. Here are some tried and true points that every biller should know to address a true appeal correctly.

Know Your Coding

In today’s multitasking office you will often find billers who are certified in both collections and coding. If you are a biller who is not certified, this is an area of growth potential. I would recommend that you consider receiving training and certification in coding. This is as valuable on the back-end for billing, as it is on the front-end for coding.

We need to think of coding as a second language. Being bi-lingual in the medical world is a real asset and will help you when researching a denial. Being able to accurately translate the codes in comparison with the medical records will give you a leg up in accurately addressing a denial.

As part of your appeal process you will need to ensure that all charges were captured correctly and accurately, that all addendums such as modifiers were used correctly, and that all ICD-10 codes are correct and complete.

Know Your Medical Terminology

You will need to master medical terminology. Being able to understand what services were rendered, any complications, or situations that would make an insurance carrier reconsider a denial will be found within this terminology. Knowing medical terminology could be the difference between payment and loss revenue.

Know Your Contracts

To ensure that you are receiving accurate and full reimbursement from your carriers it is critical that you know your contracts. Your contract is a wealth of information. The contract defines the parameters of:

  • Reimbursement Rates
  • Billing Guidelines (CMS or specific to the carrier)
  • Authorization Requirements
  • Limitations or Frequency issues
  • Non-Benefits
  • The benefits are endless!

Knowing what is expected regarding coverage and reimbursement will help you to clearly state your case when an appeal is necessary.

Author : Chelle Johnson


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