Appeals-Processing KNOW MORE

APPEALS PROCESSING

Appeals are an important part of the medical billing process. Appealing on a denied claim with sensitivity to its specific timeline is critical for the healthcare provider to recoup the money. Moreover, if you are able to identify a pattern in claims that are denied, and the existing practice isn’t helping much when it comes to appealing on those claims, it means the physician or the healthcare provider is not aware of compliance issues or guidelines, and the current billing process is incorrect by default.  It also goes to show that the healthcare provider or the physician isn’t doing much to rectify these errors.

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    AT QWAY WE IMPROVE YOUR APPEALS PROCESS BY

    Using a strategy for Appeals: Most of the time it is so, that the healthcare provider is unable to appeal on every denied claim. Focusing on the high $ value claims and leaving out claims of smaller denominations may have a potential chance of reimbursement after appeal. At QWay Health we devise an appeals strategy that is sure to deliver results. It is also a proven way to have you appealing on all the right claims in order to make the efforts worth the returns.

    Categorizing and Tracking Denials: We categorize denial by type/person.  This methodology helps us identify patterns in denials and enables us to streamline the process.

    A strong Appeal letter: Using a standard template to draft an appeal letter may not be a wise thing to do. We customize every appeal letter based on the type of denial. While we take all the necessary precaution to include important details we quote industry guidelines, CMS and CPT guidelines and the payer’s reimbursement guidelines to give the appeal a higher likelihood for clearance.

    Appeals Processing at QWay is done just the right way, at the right time and with the right documents and only for the claims deemed fit.

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    PATIENT DEMOGRAPHICS ENTRY SERVICES FROM QWAY WILL CAPTURE

    PATIENT DETAILS

    Patient name and ID#, Gender, Marital Status, Email, Date of Birth, Social Security Number, Contact numbers work and home and Address work and home.

    GUARANTOR / ACCOUNT DETAILS

    Guarantor Name, Date of Birth, Work and Home Phone and Address details.

    INSURANCE DETAILS

    Insurance Identification Number, Name and address of the Insurance company, Group name/ group number, Details of the policy and policy effective date and termination, policy number, Name of the insured, Date of Birth and the relationship of the insured to the patient.

    FREQUENTLY ASKED QUESTIONS

    • 01. What are the three steps in internal appeals process?

      A. Filing a claim: A claim is usually considered as a request for coverage. Health care providers will file a claim to get reimbursed for the costs of treatment or services.
      B. The health plan gets denied: The insurance companies must notify healthcare professional in writing and explain why:
      1. Within 15 days if you’re seeking prior authorization for treatment.
      2. Within 30 days for medical services already received.
      3. Within 72 hours for urgent care cases.
      C. Filing an internal appeal after the claim is denied by the insurance companies.

    • 2. What you need to do for filing an internal appeal?

      A. Complete all forms required by your health insurer. Or you can write to your insurer with your name, claim number, and health insurance ID number.
      B. Submit any additional information that you want the insurer to consider, such as a letter from the doctor.
      C. The Consumer Assistance Program in your state can file an appeal for you.

    • 3. How long does an internal appeal take?

      A. Healthcare provider’s internal appeal must be completed within 30 days if your appeal is for a service you haven’t received yet.
      B. The internal appeals must be completed within 60 days if your appeal is for a service you’ve already received.

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