Tip: Improve your written appeals

1. Gather necessary information. You'll need the medical chart, as well as the case management and discharge planning notes, which should include documentation of any communication with the health plan during the concurrent review and discharge planning process. You should have that plan's medical necessity review criteria and the denial letter from the insurer. For maximum effectiveness, have the patient's written consent make you-the hospital-the designee for an appeal on his or behalf.

Note: You are going to send this letter via certified mail, return receipt requested, starting the turnaround "stopwatch" and documenting to any reader that you are keeping track of turnaround time-stipulated for member appeals by either state or federal regulation.

2. Create the body of your appeal. Start with the insurer's denial letter and address what they have denied and their rationale. Using the medical information found in the chart, build an argument that concentrates on the following factors:

Note: You can and should express these important facts as an integrated and high-level interpretation, in the style and language of a physician. Don't say, "the patient's potassium was 2.8. He remained on telemetry." Say instead, "because the patient's hypokalemia placed him at risk for fatal cardiac arrhythmias, careful electrolyte correction and cardiac monitoring were undertaken. This could not have occurred in any setting other than in an acute-care hospital." Along with a reference to relevant criteria from the insurer's medical necessity reference, this is sufficient.

3. Finish with a clear and convincing conclusion. In relatively plain language, summarize in one, or possibly two sentences, the basis for overturning the adverse determination. There's no need to state the next steps in the appeal process because it is clear from the first paragraph that you have been designated by the member to appeal this on his behalf. It is best to leave the concluding paragraph as bare as possible so your summary rationale is visually prominent.