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Make a claims denial comeback


Pharmaceutical Representative

Drug denials got you down? Know your right to appeal.

After months of trying, you have finally convinced that big account to prescribe your drug. Everything is going great. The hard part is over, right?

Then, without warning, it happens. One morning, as you are innocently dropping off a dozen bagels, the nurse says, "Your drug has been denied, so we're switching back to that other drug." Panic sets in. What can you do? Know your account's appeal rights!

A well-written appeal letter to the patient's payer can be a very effective tool for obtaining appropriate reimbursement for a denied or underpaid claim. In fact, it has been estimated that only 10% of denied claims are appealed, and of those, 90% are subsequently paid upon appeal by the provider.

You can be a key part of the appeal process by assisting your accounts in the step-by-step process of evaluating and resolving the claim in question.

Compose a claims checklist

Begin working on an appeal with the account's billing manager.

You will first need to help him or her determine why the claim was denied or underpaid.

Use the following checklist for guidance:

• Look at the Explanation of Benefits and determine why the claim was denied or not paid in full. Most denial codes are defined on the back of the Explanation of Benefits form.

• Review the payer's allowable to determine if the claim was underpaid.

• Verify that your request for a review is made within six months from the date the original claim was processed. Most payers have a statute of limitations on appeals.

• Check the date and place-of-service code on the original claim.

• Verify the claim for complete coding, including J codes, ICD-9 codes and service codes, such as CPT codes for procedures and Evaluation & Management services.

• Check to see if there are any published policies from the payer that give specific ICD-9 diagnosis codes or billing instructions to be followed when billing for this drug.

• Confirm that the billing manager entered the correct number of units for your drug.

• Verify the health insurance claim number, and make sure it is current.

• Determine who the primary payer and secondary payer are.

Draft a letter

If any of the information on the original claim is not correct, it may be a simple process of resubmitting the claim to the payer with the corrected information. There are some payers who will take this information by phone and process the claim as they talk with the office.

For those situations where a letter of appeal is necessary, you and the billing manager may need to draft a letter. A one-page cover letter can pack a lot of power if you attach solid clinical documentation that supports your drug's use in the setting in which it was denied. Here's what to include, step by step:

First of all, reference all attachments in the cover letter. Documentation you may want to attach to the letter includes:

• Copies of relevant explanations of benefits.

• Articles from peer-reviewed medical journals that support your case. This information may be obtained by the billing manager or via your reimbursement hotline or professional affairs department.

• Summaries or reviews from medical specialty societies. The Association of Community Cancer Centers, for example, can provide you with their most current compendia-based drug bulletin, which summarizes compendia support for cancer-related drugs.

Start your letter of appeal by stating exactly what you are appealing. If you are appealing a partial payment, include the amount charged and the payer's allowable. If it's a Medicare claim, you may want to attach a copy of Medicare's drug allowables from a recent Medicare bulletin, which the billing manager should have available.

If you are appealing a medical necessity denial, begin your letter by telling the payer you are appealing a denial and include the payer's original reason for the denial. Describe the patient's condition and treatment, and explain why the service was provided. Include any positive outcomes the patient experienced due to the treatment provided.

Also, provide any positive outcomes of patients with similar conditions treated in the past. Sometimes the person reviewing the appeal does not have a strong medical background, and you may want to request the appeal be forwarded to the payer's medical review department.

Remind the payer of existing coverage laws for off-label uses of drugs that treat cancer, AIDS and other life-threatening illnesses. If you don't know any of these laws, get them from your company's reimbursement hotline or the physician's state or national specialty society. Conclude by telling the payer that, based on the information provided in your appeal letter, you believe they should provide coverage for the treatment or adjust the amount reimbursed.

The physician should review the letter, make any changes, and sign it. The office manager's name and phone number should be referenced in the letter in case the payer has any questions.


Meet with the office manager within 30 days to check the status of the appeal. If your company has a reimbursement hotline, you can offer to have them follow-up on the status of the claim for the office.

What if the claim is still denied? If you're unsure of the payer's appeal process, call the provider line and ask. Most payers provide appeal options beyond the review level described above. For instance, with Medicare claims, if the claim is at least $100, you may request a review with a hearing officer. If the claim is at least $500, you may request a hearing with an administrative law judge. And if the claim is at least $1000, you may request a federal court review.

Just remember that if you want that big account to keep using your drug, it's up to you to help them get reimbursed. PR

Anne Kerner and Mary Lipinsky are managers of medical economics and Becky Hayes is a former manager of medical economics for Immunex Corp., Seattle. They assist oncology customers with resolving oncology reimbursement issues with insurers.

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