Top 3 things to win a claims appeal
By Jin Zhou, DC

Claim denied. How often have you seen those words on an explanation of benefits (EOB) document?

But a denied claim does not mean you will not be paid. You can make an appeal.

Making an appeal is not a simple process; you will need to learn how to defend your interests zealously. Nor is the appeals process cost-free or quick and easy.

But if you want to get your due:

1. Know the facts in your specific case;
2. Know the law and its procedures; and
3. Prepare yourself for a long ordeal.

Then be prepared to work diligently and tirelessly. The result will pay off: Those who deny your claims will back down once they see that the cost of battle will exceed the bounty.

KNOW YOUR CASE

You must know the facts of your own case. Assuming that your recordkeeping is exemplary and that a denial has not arisen from mere technicalities involving patient case notes, you need to understand why the claim was denied.

The reasons are provided on the EOB document, which is paper an insurer issues when a claim is processed.

The EOB lists each procedure for which you claim payment, one per line. Every line that is denied or delayed is annotated with a code.

If you do not understand these codes, find out what they mean. Training materials are available. Likewise, calling and talking with insurers will give you answers (their justifications).

KNOW THE LAW

In appeals, the law is your friend, but you must know your friend well. Each has different rules and players:

• CMS/Medicare or ERISA. Federal rules apply to these claims. ERISA and CMS/Medicare federal laws apply to up to 95 percent of the claims you submit. This is because ERISA applies to insured employees, and CMS/Medicare applies to retirees.

• Workers' compensation. State laws apply.

• Personal injury. Tort law is used to form the final decision.

Responding to each type of denial requires strict adherence to its particular rules and regulations.

For example: If you have a Medicare claim, you must process it through four layers of administrative review before it will be heard in a judicial review. You have the opportunity to win at any of these reviews. But, to win — or to get the opportunity to take it to a judicial review — you must be diligent about filing all paperwork within defined time limits.

Many appeals are lost simply because doctors fail to file the written paperwork within the appropriate deadlines.
The same admonition applies to ERISA claims (claims against insurance companies). To be heard on appeal, however, a denied claim must first go through an administrative review.

It is essential to understand and follow the procedure for each type of appeals claim.

Workers' comp and personal injury cases require adhering to the regulations within your state.

PREPARE YOURSELF

Insurers have a lot of resources on their side — money, attorneys, and time. They use these resources in a face-off.

Each step of the appeals process — regardless if it is a state or federal claim — takes time. Be prepared to wait to win your case. It may sometimes feel like a David vs. Goliath battle, but remember that David won.

Knowledge brings power. Learn what you need to know. Those who refuse to pay you in most cases do so simply because they can get away with it. Their experience tells them that most doctors do not fight, or fight for a short while and then give up.

But if you arm yourself with knowledge and fight the righteous fight, insurers will back down.

SIDEBARS:
What is ERISA?
ERISA appeals and traffic court By Rick Lehtinen

Jin Zhou, DC, is a practicing chiropractor in Chicago. He also maintains the appeals Web site, www.erisaclaim.com, and lectures nationwide on the appeals process. He can be contacted at erisaclaim@aol.com.