How to Use a Five-Part Approach to Appeals

Patient stories put the pulse in any healthcare communication – including appeals.

Unfortunately, appeal letters generated from a healthcare organization often lack the persuasive impact that a first person appeal contains. However, customizing appeal letters to better present the patient story can often be accomplished by bringing in the patient’s personal narrative information from the medical records.

Is this difficult? It often comes down to the quality of the clinic documentation. When reviewing medical records in preparation to develop an appeal, look for any patient information that will give the payer a better understanding of the progression of the patient’s condition and the specific impacts to the patient’s normal activities. For example, it doesn’t hurt to point out that the avid golfer is sidelined by his/her condition. Medical records often contain bits of patient narrative which describe succinctly why the patient is seeking out medical care.

“Open all meetings with a patient story—good or bad—and make sure the importance of patient centricity is the message communicated at all leadership meetings,” states the Press Ganey whitepaper “A Strategic Blueprint for Transformation Change.”

While this is good information for internal meetings, it may even be more applicable to patient appeal development, according to Tammy Tipton, president of Appeal Solutions.

“We train thousands of healthcare organizations on getting better about being the patient’s voice in the appeal. There is a lot of attention to the technical pieces of the appeal but the patient story is often what really sets a good appeal apart from what looks to the payer like a form letter appeal.”

Further, Tipton said, payer reviewers often do not have a practical understanding regarding the patient education and decision-making process. If you want to improve the patient appeal letter, look for ways to fill in this dialogue and demonstrate the shared decision making efforts your clinicians go through daily. If your organization conducts prior authorization appeals, details regarding decision-making and conditions under which the decision are made can be compelling to reviewers who are looking for reasons (some really do look) to stray from their internal guideline and approve care.

If you contrast patient appeals letters with those drafted by healthcare organizations, you will quickly see that these types of details are very prevalent in patient appeals but are overlooked in healthcare organization appeals. Appeal specialists are often overly reliant on technical arguments and ignore the patient’s core complaints and values, said Tipton.

Furthermore, developing more patient narrative in appeals can have an impact on patient engagement and, if provided with a copy of the appeal, may motivate the patient to take up other avenues of dispute resolution such as external review and even litigation, if necessary.

“The term “patient-centered care” has become so familiar that its true meaning as it applies to the over-all care experience can get lost. Often, patient-centered care becomes a “lapel-pin campaign,” without significant depth in the organization to drive meaningful cultural alignment. The only way to fully deliver on the promise of patient-centered care is to define, communicate and integrate it in such a way that it is mirrored in every action, interaction and reaction across the organization. When such a culture prevails, all of the interdependent performance measures reflect it,” states the Press Ganey publication referenced above.

Many patient finance experts are trying to bring a “patient-centered care” approach to business office functions. However, achieving this goal really requires bringing payers along in this improvement initiative. Many of the “interdependent performance measures” can only move in the right direction if payers are cooperative which often means putting pressure on payers via an aggressive appeal initiative.

It may be necessary to ramp up patient advocacy efforts so that payers know they will expect to hear from your organization regarding any impact to treatment – from access to payment. You can improve your appeals by following the following 5-part approach to appeals. When developing an appeal letter or customizing an appeal letter template, review the letter to see if it addresses the following five consideration points:

Intro paragraph with clear “appeal initiation” wording

It is good to start the letter by stating basic claim information and giving the denial reason. This paragraph should also indicate your desire to appeal the denial. Further, if you have obtained specific instructions in the denial letter, reference this information.

Paragraph(s) providing a Customized Treatment Summary –

Most appeal letters will be optimized for success by providing a customized treatment summary. This summary can range from a few sentences to several paragraphs, depending on claim variables such as denial type and complexity of care. If the denial type is “lack of medical necessity” the treatment details need to be more comprehensive in order to establish medical necessity. However, denial types of a more technical nature, such as lack of timely filing, may not require as many clinical details. Complexity of care will often require a more detailed discussion of clinical information. Further, be sure to present a “personal narrative of the patient” in this section by selecting portions of the medical record which present the patient’s first-hand account of medical challenges. Or, if treatment is complicated by unique patient challenges, be sure and review how the physician developed a treatment plan specific to the patient’s expressed desires and needs.

Paragraph providing a Customized Treatment Coverage Summary –

Every appeal letter should give a brief summary of the understood coverage terms. This portion will cover any preauthorization, referral or verification of benefits extended by the insurer prior to treatment. Although this type of communication is often provided by insurers with stated limitations such as “this is not a guarantee of payment,” pre-treatment comunication still often act as an “inducement” to provide treatment. Therefore, it is important to cover this information and preserve any rights to argue the inducement issues in later appeals or legal filings. You would also want to include any managed care contract specifics which you believe apply to the appeal review.

Basis of the Appeal –

This portion of the appeal should clearly state why coverage should be allowed. Be sure and reference as many objective sources of information as possible. This section should also reference any internal clinical guidance your practitioners utilize in developing a treatment plan or any third-party coding resources which support your coding selection. Further, state and federal rulings/guidance should be cited in this area.

Demand for Information if Denial is Upheld –

The Demand for Information if Denial is Upheld is one of the most overlooked components of an effective appeal letter. An appeal level should always state that the payer should release any internal guidance, expert opinions, claim information and/or patient information used to reach the decision. This will allow you to assess if the relied upon information is timely and appropriately applied. Often, because payers can be very protective of internal guidance, the appeal process is one of the only means to obtain this type of internal information. However, certain state and federal disclosure laws often require the release of this type of information to qualified parties. If the payer refuses or ignores this request, it is often worth a follow-up letter citing any applicable legal protections and supplying any patient authorizations that payer may require.