Prompt Payment Appeals: Saying “What is Taking So Long” in Optimal Wording

While some initial reports on ICD-10 claim processing have been favorable, many providers are experiencing payment delays and other revenue cycle challenges related to the coding transition.

Both CMS and RelayHealth issued claims processing reports reflecting little change in denial rate metrics. According to the CMS report, denials for October, 2015 were about ten percent of submitted claims. CMS has received an average of 4.6 million claims per day and 2 percent were rejected to incomplete or invalid information and 0.09 percent were rejected due to invalid ICD-10 codes. A total of 0.11 percent were rejected due to invalid ICD-9 codes. A total of 10.1 percent of total claims processed have been denied. The baseline rate is 10 percent.

RelayHealth is providing daily updates to ICD-10 performance metrics at!/advisor. They reported denial rates of 1.6 percent in October and 1.7 percent in November. Reimbursement rates and days to payment also appear in line with pre-ICD10 claims data.

While the hard data is looking favorable in the early transition stages, a industry survey of providers found that only 80 percent of providers feel they have made a successful transition. Perhaps more disconcerting, eleven percent would call the transition a failure. This report issued by KPMG is located at

“Organizations are beginning to see dips in cash flow due to payers delaying the processing of ICD-10 claims while they ensure their ability to appropriately adjudicate these claims, while others are seeing an increase in claim denials over pre-ICD-10 levels” said Craig Greenberg, KPMG director, advisory.

Due to continued uncertainly regarding payer performance, your ICD-10 planning should include a review of your process for escalating aged claims which lack a clear payer response. Make sure that once a claim is identified as aged beyond the prompt payment requirements for the payer and claim type, it is escalated with the payer by citing the prompt payment requirements. Make sure that financial reporting is correctly capturing the impact of pending claims on a payer-by-payer basis.

Also, keep abreast of payer-specific ICD-10 claim filing guidance pertaining to pending claim resolution. Many payers have an established ICD-10 contact person who may be able to provide guidance on resolving pended claims.

Finally, as you address pending claims, be sure and include clear demands for a prompt review and response. Some payers may regard your prompt payment inquiry as merely an “inquiry” and not provide a detailed response. Consider wording such as the following which makes ts clear the prompt payment is a compliance issue you are prepared to address through all necessary means:

We request immediate payment of the above referenced claim. According to our records an ICD-10 compliant claim was promptly filed. However, payment has not been received.

It is our position that applicable payment regulations and/or contractual stipulations likely require your company to process claims in a prompt manner. Therefore, we request your written response outlining the reason for your delayed response. If benefits are delayed due to ICD-10 readiness, please provide confirmation that the claim was received, a projected processing date and the specific reason for the delay.

We appreciate your prompt attention to this matter.

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