April 15, 2022

Tactics to Successfully Appeal a Denial Letter

Tactics to Successfully Appeal a Denial Letter 2When creating an appeal letter, clarity and brevity are essential to increasing success. Now more than ever, overturning denials is critical for hospitals’ revenue cycles. The tight United States job market and unprecedented inflation put tremendous pressure on businesses to support wage growth. Wages and benefits are the greatest expenses for US hospitals. The lack of a proactive denial strategy will undoubtedly hurt these systems’ net revenue.

Hospitals facing unprecedented self-denials require a physician advisor who understands how to win cases is an essential financial advantage. Receiving a denial letter is not a hospital failure but rather an opportunity to go after as much as you can. My approach begins by understanding the basis of the denial and the standards utilized to justify it. UR guidelines need to be satisfied in the appeal letter and organizing them as a narrative helps build your case. After accomplishing this, you know how you will write the story before actually starting the letter.

Once you are ready to format your appeal, consistency is the key to accuracy and speed. The structure of a letter to appeal a denial breaks down into three major sections: summary, justification, and conclusion.

1. Summary of the Case

  • This section is about building a narrative, so it is vital to give some background on the patient. Some key features are identifiers (name, age, gender, etc.), abnormality trends, inpatient order and discharge dates, and day-to-day accounts. The primary focus should be on emphasizing abnormal findings. The inclusion of standard conclusions will not only make your letter too long, but it could also provide ammunition that could be used against your case.

2. Justification

  • This section is where you will make your case, so it is advantageous to combine multiple strategies. Highlighting the persistence of abnormalities, specifically cited criteria like MCG or Interqual guidelines, and risk calculations are key to include in this section. Peers may have a different interpretation of each criteria point, so it’s best to mention multiple points.

3. Conclusion

  • This final section is your quick “30-second elevator pitch” that helps seal the denial win. Reiterate how the case met MCG/IQ guidelines and keep it short and sweet. Brevity is important—my letters are usually no longer than a page and a half.

Once essential elements such as grammar, spelling, and professional appearance is solid, your letter is ready to be reviewed and accepted.

These steps can apply to a myriad of case appeals. Here are a few examples of Sound appeals and how the basis and justification outlined in the letter successfully overturned the denials.

Case 1: 68-year-old female patient with COPD who was transferred to a higher-level facility out of concern for CAD.

  • This denial was based on a lack of transfer justification. The appealer used relevant portions of the MCG criteria to prove a transfer was necessary. The patient was found to have 2 serious comorbidities, thus requiring a high-level transfer. 

Case 2: 71-year-old male patient with vomiting, diarrhea, and comorbidities. He was denied for a diagnosis of AKI suggesting that the patient’s admission was due to a small bowel obstruction.

  • This denial was based on inaccurate clinical information. Relevant MCG sections matched diarrhea/gastroenteritis and bowel obstruction symptoms that worsened for the patient over time.

Case 3:  A 32-year-old man with worsening cellulitis despite outpatient care.

  • This denial was based on the belief that the patient had not attended outpatient therapy. Since he had attended, the MCG criteria for cellulitis best matched the case. This was justified by the worsening of his condition over the time he was in the hospital. 

The most important thing to remember is to not get discouraged when you receive a denial letter. Some payers fail their due diligence, and cases can be reviewed inappropriately. As shown in the cases above, taking the time to find due justification can save your hospital thousands. Adhere to your process, and don’t give up!

If you would like to view the webinar “Tactics to Successfully Appeal a Denial Letter,” click here.

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