By Martine G. Brousse
Patient Advocate, Certified Mediator
August 8, 2022
In a separate blog I have examined the 7 most common reasons to file an insurance appeal.
However, appeals are not the answer to every denial, rejection or incorrect processing of a claim. Avoiding wasted efforts and time, assured future rejections, and ultimately the lack of desired results is why NOT filing one is sometimes the best strategy.
Here are 6 reasons NOT to file an appeal:
BUT FIRST, WHAT IS AN APPEAL?
An appeal is a request sent to an insurance asking for a review of a decision, of a denial of coverage or of how a specific claim was processed (Explanation Of Benefit).
This is the right of a plan's subscriber, as well as a provider, to ensure that charges have been processed - and paid - at the highest rate possible and in accordance to the terms of the policy and legal mandates.
WHEN NOT TO FILE AN APPEAL WITH YOUR INSURANCE?
1. The patient’s demographic info is incorrect:
If the provider billed your old plan, if the ID # is incorrect, if the patient’s date of birth or other info is not exact, the claim(s) will be rejected.
Even if the EOB shows "no coverage for this patient", the issue is a data entry error, and therefore cannot be appealed. Once the provider submits an updated claim with the corrected demographic info on it, they will get paid.
2. The provider’s invoice is incorrect or missing info:
Too many invoices I have seen lack important info such as a Tax ID# or NPI # (individual personal ID# for medical providers).
Patients paying up front and cash for medical services should make sure that the invoices they receive and then submit for reimbursement to their insurance show the following:
o Name, title, address, tax ID# and NPI# of the provider who rendered the service
o CPT and/or HCPC code (indicating which procedure was done, or supply/Rx dispensed)
o ICD-10 code (specific diagnosis associated with the service or supply)
o Any authorization number obtained ahead of time
Missing info on invoices is not a valid reason to appeal, as the insurance is unable to process the claim through no fault of its own.
3. Coding mistakes:
Coding medical procedures, supplies, medications and services is complex.
Finding the most appropriate diagnosis code among 68,000 codes (medical) or 87,000 codes (hospital) can be challenging.
The most common mistakes involve an incorrect diagnosis code ("ICD-10") to a specific procedure (CPT code) or supply/drug (HCPCS code).
For example, coding a cholesterol blood test with a cancer diagnosis, or coding an appendectomy with a high blood pressure diagnosis will result in rejections.
Even if the diagnosis codes truly belong to the patient, each should be matched to the specific service they were ordered or performed for.
These errors can only - but easily - be corrected by the provider's or facility's billing department. Once the updated claim is submitted, the claim become payable.
4. Incorrect claim address:
Although claims are mostly submitted electronically these days, the code for the insurance address must be the right one. Some insurers have franchises in different states, and might not use a general claims address.
Blue Cross Blue Shield for example must be billed in the state where services were rendered, even if the plan is from another part of the country.
Filing an appeal will result in a denial. Until the provider submits their charges to the correct address and local plan, no claim is payable.
5. Incorrect HMO payor
The medical group you belong to (“IPA”) is usually responsible for the payment of your claims. Under some circumstances (emergency out of your area for example) claims are payable by the insurance itself.
If the IPA rejects a claim as “not our responsibility’ the claim(s) in question should be forwarded to the healthplan.
If the healthplan rejects a claim as “not our responsibility’ the claim(s) in question should be forwarded to the medical group.
A good rule of thumb is: whoever issued the referral or authorization is to be considered the financial responsible party.
6. Billing the wrong type of insurance
Some claims might be sent to the wrong plan.
o claims relating to dental issues might be covered by the medical plan, not the dental plan.
o Some eye surgeries, such as cataracts, are covered by the medical insurer not the vision plan
o Some medical services such as anesthesia might be covered under the dental plan if performed for dental-related reasons
In such cases, there is no right to appeal as the right payor was not billed.
The EOB should clearly indicate which plan to submit the charges to.
While receiving a denial from your insurance will certainly cause anxiety and frustration, the reasons highlighted here are easily remedied and corrected. It might cost you a phone call or two, or submitting a copy of your new insurance card to the appropriate billing departments.
Filing appeals in such cases will never result in a win as such claims are deemed “unprocessable”.
As for changing any code yourself, don’t even think about it. Only the provider can legally – and should! – change any code or update any claim.
Martine Brousse is a Patient Advocate and Certified Mediator located in CA and the founder of AdvimedPro, which she started after working 20 years as a billing manager for physicians.
@ Martine G. Brousse 2022