"Since 1997 our mission has never changed: Help Professionals like you combat denied claims and get paid what you deserve."
A Special Note from Tammy Tipton, our Founder & Appeals Guru
What Is The Goal of Your Appeals?
Is it to win the appeal?
Is it to get the appeal written quickly so that you can move to the next task?
Is it to call attention to what the payer is missing?
These are all potential motivations. Any professional, experienced medical biller or appeal specialist wants to win, perform efficiently and raise the right issues in the appeal. However, these motivations often fail to see us through the slow, often unsatisfying cycle of appeal development, appeal tracking and appeal avoidance initiatives and training.
I have been working in denial management for more than 20 years. In the beginning, denial management seemed far removed from patient care. I envied the doctors and nurses who can see the results of their efforts in the faces and limbs and scans of their patients. How powerful! And then I received a letter of heartfelt gratitude from a patient whose denied claim I was able to overturn.
"I worried about the bill all the time," he wrote. "I am so grateful you knew what to do. My insurance company is even paying some related bills your appeal did not mention. I am so relieved."
This patient could not fully enjoy the health gain he achieved because of the hit to his financial health. It happens all to often.
Appeals are about patient care. It is about what kind of care each patient gets and when and it is also about how much and for how long we care about the patient. Patient care is the best motivation for action. If we see denial management as being critical to quality of patient care, we are much more engaged and sustained through all the small parts that need to be performed, researched, communicated and enforced.
I hope our resources make you more likely to win your appeals. I hope these resources allow you to develop appeals more efficiently. I hope I have developed appeal wording that helps you raise specific issues with clarity and force.
However, I even more strongly hope that your patients feel well cared for, from beginning to end, and that you see yourself as part of that care.
There is a lot of information here. Don't be overwhelmed but, instead, break up the content into what seems most applicable to your needs. Let me know what works well and what needs more attention. Let me know what your results are. And thank you for your investment in our resources.
I am pleased to be part of your care-focused team!
Patients need us.
Bankruptcies resulting from medical debt affect millions each year. The emotional toll on patients of any denial is significant and patients are often at a loss regarding what to do. They may not tell you that medical debt impacts their health but it likely does.
Staff education is critical
Many factors impact appeal review – utilization review, coding, documentation but many protections apply too: consumer mandates, contract terms, care standards. It is overwhelming to patients and we are their advocates. We have put together the only one stop education resource for all things applicable to denial management – from day-to-day tasks to process improvement.
Resources should be powerful.
Payers have a lot of resources to bring to claim review and denial defense. Be ready with your own airtight arguments and make sure your appeals get their full attention.
Persistence is Absolutely Essential.
The highest quality review occurs at the highest level of appeal but you can't get to that level without exhausting lower level appeals. Use our resources to stay in the game for the long haul.
Legal information is more important than ever.
The legal implications of appeal review are growing. More mandates mean more compliance issues for payers. Your letters must cover potentially applicable legal protections in a way that forces a detailed payer response. Quality dialogue is crucial to all parties – patient, provider and payer – but you have to demand it.
Providers don't really get quality appeal review.
Most of the protections related to appeal review apply to the patient. When providers represent the patient in appeals, the payer often does not abide by the protections applicable to the patient appeal process. Know your rights to a full and fair review. We cover this issue in detail with legal citations.
Time on denials is time away from current claim demands.
The resources you use should make you more efficient. We provide many resources to allow you to more easily launch denial avoidance training so your denial rate heads in the right direction.
Healthcare is being asked to do more with less.
Every healthcare organization is under pressure to lower costs as the impact of cost inflation is daily news. Our resources help organizations be effective at denial management without relying on outsourcing claims to costly third-party recovery organizations. A denied claim can cost around $100/claim to work internally but once outsourced, the costs increase dramatically.