Article of the week: Filing an appeal? Don't panic

 Noncoverage of certain conditions-or the patient. It's uncommon, but it can happen. Patient X receives therapy services and you, the provider, send the claim to the payer the patient provides. Lo and behold, you receive notice from the payer that it does not cover the patient, Hillyer says.

Or you may receive a remittance from the payer that notifies you that while it does cover Patient X, it will not reimburse for either the service or the condition resulting in the delivery of therapies, he says. "The patient may have taken a new job, and the [new] insurer will deny the claim because services resulted from a preexisting condition," Hillyer says. "Or perhaps the payer will say the condition is treatable, but [it] does not cover OT or PT services at all."

 Limited reimbursement or caps on services. More commonly, outpatient rehab providers will receive notice from a payer that it will reimburse their services-but only on a limited basis. Perhaps the best-known example of this is the Medicare therapy cap, which starts July 1. "There may either be time limitations or dollar limitations," Hillyer says. "That means some patients may have a 60-visit lifetime coverage for PT services, or the insurer will place a $4,000 maximum on PT services, or a maximum on services delivered for a certain condition."

 Professionals not authorized by the payer perform services. Under this scenario, an athletic trainer within your PT practice delivers a service to one of your patients. You submit the claim and receive notice that the payer will not reimburse you for the service, which required a PT. "The service must be delivered by a licensed person for that respective profession," Hillyer says. "The [payer] may say, 'We'll pay for cognitive training of this particular patient if it's performed only by an OT.' These types of requirements leave out exercise physiologists, massage therapists, and athletic trainers."

 The services are not medically necessary. Last but not least, the payer's decree that the service provided was medically necessary is one of the most common reasons for claim denial-and a likely candidate for an appeal in most cases, industry experts say.

"They will deny for services that are not generally accepted standards of treatment," Hillyer says. "It's a question of who the patient is, what the treatment is, who the therapist is, and finally whether they have a limit on the number of visits and how long the visits go on. The [payer] will determine what is considered reasonable and necessary and, based on review of the claim, they can deny it. They will say that either you knew or should have known that this would not be covered."

Prevention and reaction key when filing appeals
While providers often are unable to predict when appeals will happen, there are steps they can take to cut down on their number, industry experts say. And once you receive that denial, there are some key items you will want to keep on your to-do list once you decide to appeal that claim.

Check with the payer before you start providing therapy services. The number one area to focus on when it comes to appeals-prevention-takes place before you ever file the claim. Make sure that you're aware of the specific criteria and limitations before you file the appeal. Hillyer recommends that providers assign someone from the business office to either check with the insurance company or review any existing contracts for criteria before the start of treatment.

"If you're not going to get paid, it helps to know that ahead of time, as well as the reason why," Hillyer says. "The best way to avoid a denial is to only provide services consistent with the agreement already made with the payer. If you're working with a patient covered by an insurer, and you know that insurer only pays for eight visits-and three units of treatment for each visit-you've got to make sure that's what you're doing."

Decide whether you should appeal the claim. The key to this is to look closely at every denial you receive, says David Perry, PT, MS, director of Gentiva Orthopedic Services in Southfield, MI, and owner of Perry Therapeutics, a consulting company in Grosse Pointe Woods, MI.

"If you don't have good documentation to support your case or you weren't following the particular rules and regulations, then it would be an exercise in futility. But if you think you have a good case, then go ahead-appeal it," Perry says.

When deciding to appeal a claim, there are several items you should keep in mind, Perry says. Remember that during the review of the claim by the payer, a nurse, rather than a therapist, may be reviewing the claim. "I always take a good look at a denial and see if there's a foundation for building an appeal," Perry says. "Make sure you've got good documentation to support the clinical necessity of care, and you're meeting the payer's particular specific documentation guidelines. Don't be surprised if you may have to march up several layers of the appeal process. You should take it as far as you need to go."

In addition to knowing Medicare regulations, make sure that you're familiar with the particulars of any local medical review policies (LMRPs) issued by your FI or carrier. Some of the regulations set by LMRPs may vary dramatically from the Medicare regulations, Perry says.

What about documentation? Once an outpatient rehab provider decides to appeal a claim, the next step is to decide what supporting documentation to submit. There are several factors to consider, Perry says. First, make sure the appropriate people are aware of the decision to appeal the claim. If the appeal is made on technical grounds-notes or physician orders were missing when the claim was submitted-you may be able to leave the responsibility to the front office staff. Notify therapists about such claims, especially with appeals due to clinical issues. "Whatever clinical setting you may be in, you must try to keep therapists informed as to what denials are coming in," Perry says. "Even if they're of a technical nature, you want to at least inform the clinical leadership of what's happening in case you need to modify some of the practices used to run the clinic or department."

The payer-in the remittance notice of the claim denial-may indicate which records were lacking.

"If you're fighting an appeal, and you're basing it on clinical necessity, you want to submit notes for the appropriate for the time period, whatever orders you may have, and any of the clinical documentation that supports the claim," Perry says. You also need to draft an explanatory letter that outlines the reasons why you believe the service was clinically necessary. Providers should refrain from letters in which they order the payer to okay the claim. The appeal letter should instead focus on the patient's functional limitations and the impact skilled services have on that patient.

"The letter [should outline] what the patient's functional limits were and the patient's progress," Perry says. "You need to paint the picture of why skilled care was necessary to make improvements in the patient's situation. . . . I always tell providers that you're painting a picture-it's a mural. That picture is going to tell the story of why the patient needed therapy, what was done, and what their response was to your skilled interventions. All of that wraps together and justifies why the therapies were needed."

Also, it's helpful to cite accepted standards of practice in the appeal letter. For example, when appealing claims for PT services, Perry often refers to the Guide for Physical Therapy Practice and includes the back-up material in the appeal letter.

"You should include which of the practice parameters were involved, and this can also help give you supportive documentation as to why the care was clinically necessary," Perry says. "This way, you're not just relying on or sending in notes."