11-19-01
How To Fight Payment Denials
Leslie Stein Lloyd
Exercise your right to appeal a payer's denial of payment for occupational therapy services. All practitioners receive a claims denial now and then. Denials can occur on submission of a claim, or at times, payers review paid claims (a post-payment review, medical review, or audit), determine that they erroneously paid the claim, and seek a refund (an overpayment) from you. The two keys to successfully appealing claims denials are (a) to understand the appeals process and (b) to understand the grounds for the denial.
APPEALS PROCESS
First, be sure you understand the appeal process for the payer in question. When dealing with private insurance companies, check your provider agreement for your appeal rights. Request a written copy of the plan's specific appeal procedures because the appeal process can vary from plan to plan. Private companies may be subject to state insurance law and regulations, so your state insurance commission is a good place to go for specific state rules. Contact your state Medicaid office for a written copy of Medicaid's appeal procedures.
Medicare (traditional plans) appeals are grounded in federal law and regulations. You have the option of representing yourself throughout the Medicare Part B appeals, or you can retain an attorney. You should read the appeals instructions, ensure that you understand the process, and be aware of all the deadlines that must be met to preserve your appeal rights. Those instructions are explained in detail at www.hcfa.gov/pubforms/transmit/ R1721B3.pdf (Medicare Transmittal 1721, 9/27/01).
Often, Medicare procedures are emulated in state or private processes. There are five levels of Medicare Part B appeals, each of which must be exhausted before you can move on to the next step. To begin your Medicare Part B appeal, request that the Medicare carrier review the initial determination. An initial determination is the first denial letter you receive for a claim. It will state the grounds for denying payment and set forth appeal rights. There is no live hearing at this level--it is a paper review only--so be sure to submit any additional evidence that will help the carrier decide to overturn the denial. Evidence can include excerpts from the medical record, a physician's letter of support, and further written explanations (these are usually statements that demonstrate the medical necessity of the therapeutic intervention).
If the reviewer decides that the denial was not erroneous, you can take the appeal to the next level. In fact, you have the right to take your Medicare Part B appeal all the way to federal court. Be sure to obtain a copy of the appeal instructions and read AOTA's detailed guide to Medicare Part B appeals on the Reimbursement page of AOTA's Web site at www.aota.org for more information.
GROUNDS FOR DENIAL
Understanding the grounds for a denial will help you effectively argue that your services should be paid. Carefully read the denial letter. Whether the denial is based on a law, regulation, or private insurance policy limit, get a copy of the source material. Often, state laws are posted online (see www.ll.georgetown.edu/lr/lg/state.html), as are Medicare laws and regulations (go to www.hcfa.gov). Ask the payer for the basis for the denial in writing and for copies of relevant coverage policies.
You will want to refute the payer's reasons for the denial. To make strong arguments, use AOTA's resources, which you can get from the Online Store at www.aota.org. The Guide to Occupational Therapy Practice, the Practice Guidelines series, the Model Practice Act, and the book Effective Documentation for Occupational Therapy can help you to demonstrate how your services were clinically appropriate, were medically necessary, met your profession's standards of care, and were appropriately documented. If the denial is based on the scope of practice, make sure you have read your state practice act (also available on AOTA's Web site).
For most appeals, you will interact with decision makers who know little, if anything, about occupational therapy. Seize the opportunity to educate them about the profession and about the role of occupational therapy in meeting patients' medical needs. Involve your patient, if appropriate. Using AOTA's tools and your clinical reasoning skills, you can effectively appeal denials.
Leslie Stein Lloyd is AOTA's regulatory counsel in Reimbursement and Regulatory Policy.
