medical billing services

Maximization of your appeals In an ideal scenario, claims are always paid out right away. Additionally, if a claim is initially paid incorrectly, you can phone or send a written appeal, and the payer will correct his mistake and process the claim of dental billing company. Sadly, the world is not perfect where we live. Sometimes the claim isn't processed even after the phone call and letter. In that scenario, you must adhere to your contract's specified appeals procedure.
Some payer agreements specify the appeals procedure. Many distinguish the stages of the procedure as first-level appeal, second-level appeal, and request for outside review as the last stage. In the sections that follow, I describe these stages.
Send medical records, a copy of the claim, and a copy of the explanation of benefits (EOB) that was enclosed with the payment when submitting a written appeal, whether it be a first- or second-level appeal. How the claim payment was determined is detailed in the EOB. The payer can better identify the claim and its processor by providing the EOB. Make sure the claim number is on the appeal if you don't include a copy so the payer can identify the right claim.

Preliminary appeals A first-level appeal might only serve as a reminder that the claim should have been handled a certain way in accordance with your records. It basically serves as a pleasant reminder that the terms of the contract weren't followed or that a discount was given without one. This reminder can be all you need if the issue is just a pricing one, and the payer will fix the mistake right away.
Include all supporting paperwork with your first-level appeal if the issue is that the claim was rejected due to medical necessity or another similar reason. When you do this, the payer will (hopefully) change its mind and accurately process the claim once more. Your first-level appeal can be the only one you need if it explains the justification for the request and includes any supporting materials.
Your contract likely specifies the turnaround period for appeals, which varies according on the payer. The backlog can easily grow into months when the payer has introduced new processing software and numerous claims are being paid improperly (or not at all). Verify that the appeal has been received by following up if you don't hear anything after 30 days. Your timing will also depend on the laws in your particular state because each state has its own prompt payment statute.

Secondary appeals The payer may reject your request occasionally. You must make another request in this situation. A second-level appeal is the name given to the second request. You might be able to simply mark this appeal "second level" to indicate that you've already requested resolution, or you might need to submit it to a different location.
An appeal at the second level is more official. Make sure to include the following: a precise definition of the issue and a statement that you have already made an unsuccessful request. Even a copy of your initial appeal may be included.
If you can present your argument differently in a second-level appeal, try to do so. Rephrasing your sentences can sometimes make a significant impact in the outcome of a second-level appeal.
Add all supporting documents. This paperwork would consist of things like the EOB, health records, pertinent invoices, and a copy of the contract (or the applicable section of the contract). (Note: Be sure to mark the copy of the claim "COPY" if you send one.)
Before sending a second-level appeal, check your contract. In accordance with some payer contracts, the second-level appeal is the last resort; if it is rejected, no other levels of appeal are open to the payer. In this situation, look for choices in your contract. If the money amount is sufficient, the contract may provide a third-party mediation procedure for disagreements. You can consult a lawyer if the payer is not a contracted one. Most offices have a healthcare-focused attorney on staff who can take care of your case.

Medicare processing appeal The method for appealing is laid forth by the Centers for Medicare & Medicaid Services (CMS). This procedure is simple to follow and effective. On the Medicare website medical coding services and the websites of the Medicare carriers with which you have individual contracts, you may obtain all the essential forms.