Payer Appeals Process Assists Members with Claim Denials
The Academy receives daily member inquiries and notifications regarding claim denials and payment policy issues that arise when seeking reimbursement for otolaryngology procedures from private insurers and Medicare. In response, the Academy has a wealth of resources available to members, including: CPT for ENT articles, appeal template letters, clinical indicators, and position statements to help members obtain appropriate reimbursement for various otolaryngology procedures. These resources are available on the Academy’s “Coding Corner,” which is available at http://www.entnet.org/practice/codingResources.cfm. Due to a large volume of national policy issues submitted to the Health Policy Unit, the Academy works to prioritize and respond to payer coverage issues according to the number of members or geographic regions affected by each policy. Based on time and resources available, the Health Policy department and the Physician Payment Policy (3P) Workgroup may offer assistance for issues affecting many members at the state or national level in cases where the appeals process has been exhausted and resulted in an unsuccessful outcome. Upon receipt of inquiries regarding private payer denials we work to determine whether the issue is a local or state based, or if it is a national issue that the Academy 3P workgroup should be involved in. Outlined below are the recommended steps for members who encounter difficulty obtaining reimbursement for their services. Ensure that the service was billed appropriately (e.g., appropriate modifiers used with appropriate CPT codes). Consult the Academy website for various resources to assist with an appeal for a specific service. Some helpful resources include: CPT for ENT coding guidance articles: http://bit.ly/CPT4ENT Code changes for CY 2013: http://bit.ly/2013codes Information on NCCI /MUE Edits: http://bit.ly/ENTcoding Audiology FAQs: http://bit.ly/audiologyFAQs E/M Documentation guidelines: http://bit.ly/EMguide Template payer appeal letters for services commonly denied: http://bit.ly/entappeals Do you have the local payer policy for the procedure? Access the carrier’s website, logging in as a provider, and search for the policy relevant to your geographic jurisdiction. The Academy cannot represent physician members individually on each issue with payers, but health policy staff does track the issues and monitors whether a local or state issue becomes a national issue that 3P should address on behalf of all members. Talk to the medical director to get more information on the rationale used for the denial. We have found that many times there is a better outcome when the local AAO-HNS physician members who work directly with the payer’s medical director on issue resolution address a local issue. If 3P determines that the issue is a regional or national issue that could affect many otolaryngologists, information on the payer policy and the rationale used by the payer’s medical director is helpful for Health Policy staff to determine if this is a local issue. If that information is available to forward, that is helpful for 3P to know as well. All of this information helps us as we determine the best course of action for your request, and track members in certain states who are having difficulty with specific payers. To find out how widespread an issue is, we strongly recommend you work with your state society of otolaryngology-head and neck surgery, Board of Governors representatives, and state medical society to report the issue so they may attempt to assist you. They may also be able to provide a better idea of how widespread an issue is among providers in the area. You can access contact information for several state otolaryngology societies on our website at http://www.entnet.org/Community/BOGSocieties.cfm?View=State (Login required). We strongly recommend that you also contact others in your community to determine if they are having the same issues. The Academy coordinates with the Association of Otolaryngology Administrators (AOA) Advocacy and recommends that you reach out to the AOA [www.oto-online.org] to determine if other practices are having similar issues. Since state issues are usually best resolved with leaders at the state level, we recommend administrators and their physicians contact the AOA to receive resources that others may have used in other states to resolve the issue. The Academy offers the AOA the resources that we have available, such as a comment letter, if 3P determines it could affect many members and would help with advocacy efforts. For Medicare payment issues, we often recommend you contact the Medicare Administrative Contractor (MAC) medical director directly, and contact your regional MAC’s Carrier Advisory Committee (CAC) representative. Currently, there is an ENT CAC representative designated to each state within a MAC jurisdiction (15 geographic regions nationwide). Each representative acts as a liaison between Medicare Contractors and state specialty societies. For more information on the CAC representative nomination process, or for local CAC representative contact information, email Health Policy at healthpolicy@entnet.org. The Academy encourages members to take full advantage of available appeals processes when encountering denied claims. Even in cases where you may feel no progress is made, it is important to exhaust your right to appeal in order to gather all the pertinent information necessary for the Academy to assist you with your issue. Once the recommended efforts have been exhausted, if you still believe a service is being inappropriately denied, the Health Policy team will request a copy of the Explanation of Benefits (EOB) form (with patient HIPAA information redacted) and a copy of the applicable payer policy (this includes denial letters, national or local coverage policies, or any other documentation the payer has provided you during your appeals process), so staff and 3P can determine the root cause of the payer’s denial. 3P will then determine how widespread your specific issue is and whether additional advocacy efforts are required. If you believe services are being inappropriately denied by a third party payer, or your MAC and have exhausted all appeal options to rectify payment, please contact the health policy team at healthpolicy@entnet.org. Resources: A NY State Example A current example of how your state society can assist you comes from the New York State Society of Otolaryngology (NYSSO), which provides assistance to otolaryngologists at the state society level, as part of their member benefits package, and allows NYSSO members in good standing to take advantage of free, unlimited consultation for health insurance coding and billing issues. This service is provided by the Society’s Third Party Consultant, James McNally, who assists otolaryngologists with questions about policy interpretation, use of modifiers, supported diagnosis codes, and non-payment/underpayment of claims for both public and private carriers. In most cases, physicians receive a response within 24 hours. New York members can contact the NYSSO office at 1-518-439-2020 or meetings@nyssohns.org.
Due to a large volume of national policy issues submitted to the Health Policy Unit, the Academy works to prioritize and respond to payer coverage issues according to the number of members or geographic regions affected by each policy. Based on time and resources available, the Health Policy department and the Physician Payment Policy (3P) Workgroup may offer assistance for issues affecting many members at the state or national level in cases where the appeals process has been exhausted and resulted in an unsuccessful outcome.
Upon receipt of inquiries regarding private payer denials we work to determine whether the issue is a local or state based, or if it is a national issue that the Academy 3P workgroup should be involved in. Outlined below are the recommended steps for members who encounter difficulty obtaining reimbursement for their services.
- Ensure that the service was billed appropriately (e.g., appropriate modifiers used with appropriate CPT codes).
- Consult the Academy website for various resources to assist with an appeal for a specific service. Some helpful resources include:
- CPT for ENT coding guidance articles: http://bit.ly/CPT4ENT
- Code changes for CY 2013: http://bit.ly/2013codes
- Information on NCCI /MUE Edits: http://bit.ly/ENTcoding
- Audiology FAQs: http://bit.ly/audiologyFAQs
- E/M Documentation guidelines: http://bit.ly/EMguide
- Template payer appeal letters for services commonly denied: http://bit.ly/entappeals
- Do you have the local payer policy for the procedure? Access the carrier’s website, logging in as a provider, and search for the policy relevant to your geographic jurisdiction.
- The Academy cannot represent physician members individually on each issue with payers, but health policy staff does track the issues and monitors whether a local or state issue becomes a national issue that 3P should address on behalf of all members.
- Talk to the medical director to get more information on the rationale used for the denial. We have found that many times there is a better outcome when the local AAO-HNS physician members who work directly with the payer’s medical director on issue resolution address a local issue.
- If 3P determines that the issue is a regional or national issue that could affect many otolaryngologists, information on the payer policy and the rationale used by the payer’s medical director is helpful for Health Policy staff to determine if this is a local issue. If that information is available to forward, that is helpful for 3P to know as well. All of this information helps us as we determine the best course of action for your request, and track members in certain states who are having difficulty with specific payers.
To find out how widespread an issue is, we strongly recommend you work with your state society of otolaryngology-head and neck surgery, Board of Governors representatives, and state medical society to report the issue so they may attempt to assist you. They may also be able to provide a better idea of how widespread an issue is among providers in the area. You can access contact information for several state otolaryngology societies on our website at http://www.entnet.org/Community/BOGSocieties.cfm?View=State (Login required).
We strongly recommend that you also contact others in your community to determine if they are having the same issues. The Academy coordinates with the Association of Otolaryngology Administrators (AOA) Advocacy and recommends that you reach out to the AOA [www.oto-online.org] to determine if other practices are having similar issues. Since state issues are usually best resolved with leaders at the state level, we recommend administrators and their physicians contact the AOA to receive resources that others may have used in other states to resolve the issue. The Academy offers the AOA the resources that we have available, such as a comment letter, if 3P determines it could affect many members and would help with advocacy efforts.
For Medicare payment issues, we often recommend you contact the Medicare Administrative Contractor (MAC) medical director directly, and contact your regional MAC’s Carrier Advisory Committee (CAC) representative. Currently, there is an ENT CAC representative designated to each state within a MAC jurisdiction (15 geographic regions nationwide). Each representative acts as a liaison between Medicare Contractors and state specialty societies. For more information on the CAC representative nomination process, or for local CAC representative contact information, email Health Policy at healthpolicy@entnet.org.
The Academy encourages members to take full advantage of available appeals processes when encountering denied claims. Even in cases where you may feel no progress is made, it is important to exhaust your right to appeal in order to gather all the pertinent information necessary for the Academy to assist you with your issue. Once the recommended efforts have been exhausted, if you still believe a service is being inappropriately denied, the Health Policy team will request a copy of the Explanation of Benefits (EOB) form (with patient HIPAA information redacted) and a copy of the applicable payer policy (this includes denial letters, national or local coverage policies, or any other documentation the payer has provided you during your appeals process), so staff and 3P can determine the root cause of the payer’s denial. 3P will then determine how widespread your specific issue is and whether additional advocacy efforts are required.
If you believe services are being inappropriately denied by a third party payer, or your MAC and have exhausted all appeal options to rectify payment, please contact the health policy team at healthpolicy@entnet.org.
Resources: A NY State Example
A current example of how your state society can assist you comes from the New York State Society of Otolaryngology (NYSSO), which provides assistance to otolaryngologists at the state society level, as part of their member benefits package, and allows NYSSO members in good standing to take advantage of free, unlimited consultation for health insurance coding and billing issues. This service is provided by the Society’s Third Party Consultant, James McNally, who assists otolaryngologists with questions about policy interpretation, use of modifiers, supported diagnosis codes, and non-payment/underpayment of claims for both public and private carriers. In most cases, physicians receive a response within 24 hours.
New York members can contact the NYSSO office at 1-518-439-2020 or meetings@nyssohns.org.