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Are You Facing Delays in the Appeal Process? You Might Be the Problem

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A 2017 analysis by Change Healthcare suggests that of the three trillion in medical claims per year, about nine percent are denied right off the bat. That may not sound like a lot, but it works out to a whopping $262 billion! That’s not only a problem for the patient, but it’s also a problem for the provider as well; you don’t get paid when a claim is denied, so you have to jump through hoops to appeal.

We live in a society that has ingrained within us the expectation of instant gratification. Unfortunately, there’s no such thing when it comes to claim determinations and appeals. In fact, you may be the reason why the process seems to take an eternity. Here’s why.

Providers and beneficiaries have the right to appeal claim determinations made by National Government Services (NGS). However, due to a lack of information regarding NGS’s appeals timeline, many end up submitting the appeal again for reconsideration after not hearing from NGS in a timely fashion.

This may seem counterintuitive, but resubmitting too early can cause administrative delays and slows down processing of the appeal. The appeals activities are done through NGS under the direction of CMS.

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NGS Timeline

You want to get paid, but ironically you have to have a little patience if you want to get paid quickly. NGS asked providers and beneficiaries to not to submit a duplicate appeal. That’s because the agency allows up to 60 days to process and complete your first level of appeal.

The following details the Appeal Consideration process conducted by NGS:

 

Level One

Level Two

Level Three

Level Four

Level Five

Type of Appeal

Redetermination

Reconsideration (QIC)

Administrative Law Judge (ALJ)

Medicare Appeals Council (MAC)

 Federal Court Review

Time Limit for Filing Appeal

120 days from date of receipt of the initial determination notice

180 days from date of receipt of the redetermination decision

60 days from the date of receipt of the reconsideration (QIC decision)

60 days from date of receipt of the ALJ decision

  60 days from date of receipt

  of the MAC decision

Source: NGS Appeals Calculator


Exercising patience and being knowledgeable of the process will better serve you and your practice's financial health in the long run. However, the best way to ensure faster payment is not to have your claim denied in the first place.

5 Tips for a Smoother Claims Approval Process

Some of the more common reasons for claims denial include:

  • Insufficient medical necessity documentation
  • Incorrect or missing codes
  • Incorrect or missing demographics or insurance information
  • No referral or prior authorization
  • Duplicate claims

Follow these simple tips to reduce your rate of claims denials and get paid on time:

  1. Ensure referral or prior authorization requirements have been met. This step is best done before you see the patient.
  1. Check to see if the patient’s information has changed. Always verify if the patient’s insurance carrier, home address, email address and phone number have changed since his or her last visit. If they have, update their information in your electronic health records (EHR) before submitting the claim.
  1. Check to see if the insurer’s pay schedule has changed. Try to get a phone number for the patient’s insurance provider and make sure their schedule is the same. For medical claims, you can find NGS’s contact information on its website (requires portal sign-in).
  1. Check for coding errors. You can find the latest ICD-10 codes on the Centers for Disease Control and Prevention (CDC) website.
  1. Fully utilize your EHR. Many of these simple, payment-delaying errors can be avoided if you choose the right EHR system and learn it inside and out. Look for an EHR that has machine learning capabilities; these advanced systems can proactively reduce errors that lead to claim denial.

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