HBI’s research in recent years has indicated a wide range of appeal outcomes among healthcare providers. For example, respondents to one survey noted first-pass success rates anywhere from 6% to 85%, with about half reporting between 40% and 65%. Such variation may be at least partially explained by the wide range of contributing factors, such as payer mix, denial root causes, and unique appeal processes. However, there are some common strategies that can help providers in all cases equip frontline appeals staff for success.
- Know Your Contracts
Appeal narratives are often most effective when citing specific contract terms (e.g., carve-outs and unusual reimbursement clauses) that support the healthcare organization’s claim of improper reimbursement. Furthermore, knowledge of such terms should not be limited to the contracting department, but rather accessible to frontline staff. Several organizations HBI has spoken with indicated the importance of contract management systems, which can flag payment variances and help prioritize follow-up.
- Develop Payer-Specific Expertise
Specializing appeal staff by payer can help them develop a deeper knowledge of unique payer requirements, improving both efficiency and effectiveness. Additionally, specialized staff can build a closer relationship with the payer. This is especially useful toward identifying reimbursement patterns and learning which information and communication format is most likely to get the payer’s attention, as well as convince them to overturn the denial.
- Collaborate With Other Departments
Like most revenue cycle processes, breaking down silos can improve appeals processes. Teams beyond the back-end, such as pre-authorization, clinical documentation, utilization review, and involved clinicians, can provide crucial information for a successful appeal. Collaboration can also reveal process inefficiencies and errors contributing to denials that appeals staff may not otherwise identify.
- Use Appeal Templates
Appealing over the phone (i.e., speaking with payer representatives directly) is often the best method for reaching a timely resolution. However, payers may require reconsideration requests to be submitted in writing. In these cases, it can be beneficial to utilize appeal templates, which ensure that all necessary components are included while reducing the time and resources spent crafting each appeal.
- Be Flexible
While templates may provide useful foundations for appeals, payer requirements and responses vary between insurers and may change frequently. Thus, it is important to allow for flexibility, such as providing appeals staff with a high-level checklist rather than a rigid, granular procedure. At one Eastern organization with two hospitals and approximately $800M+ in net patient revenue, this approach has allowed appeals staff to meet unique payer requirements while enabling baseline performance measurement (e.g., timely appeal submission) by department leaders.
- Know When to Escalate
Finally, knowing when it is both appropriate and necessary to escalate an appeal to a payer representative’s supervisor can be the difference between a denial being upheld or overturned. Such scenarios may include potential contractual or system issues (e.g., the payer does not respond within the required timeframe or staff uncover an unusual number of denials or variances with the same root cause), stall tactics (e.g., the payer indicates that they did not receive materials or communication), and denials on high-dollar claims or appeals that have aged without progress toward resolution.