Article

Coding

When appealing coverage decisions

How to write effective rebuttals when a payer asks for money back.

Someone in your billing staff approaches you with a letter from one of your most important insurers asking for money back (also known as “recoupment”). You look over the payer’s letter and the first chart in the list — the payer has a problem with a surgery they paid you for about 18 months ago.

All seems in order when you look at the chart by itself, but after carefully reading the policy, you note that you could have worded some things differently in your chart to help the payer see your side of things. The biller also tells you this insurer asked for a number of records about six months ago and that this was one of the services audited for this patient. What should you do next?

1. Assemble the chart.

Part of assembling the chart is pulling all of the available information you have that justifies the audited service(s). For example, with a cataract surgery, you would want the chart notes for the visit from which the doctor and patient decided on surgery on this eye, the operative notes, and a functional survey (Activities of Daily Living) done with the exam for that specific eye. If you do not have operative notes in your EMR, it is your responsibility to get them from the facility that performed the surgery. (Moving forward, it’s a good idea to always get these.)

If this is going to take longer than the payer’s timeline for receipt of the records, ask for an extension. The letter for the payer generally contains contact information and how to do this if you need it. Also, remember that you cannot modify the charts (see below).

2. Collect the payer policy.

The payer policy should be the version in effect on the date in question. It might not be easy for you to retrieve, but it’s critical to have — if it exists at all. The payer might have referenced it in their recoupment letter, so first check to see if they referenced the correct policy for that particular date of service. Since payer polices may change over time, they might apply today’s policy retroactively — if the policy isn’t the correct one, you should point that out.

Next, look carefully at the policy. Payers use words like “shall,” “must,” and “required” when they absolutely have to see certain things. They might also expect that certain things are present, such as “the patient desires surgery.” Make a note of the payer requirements, and compare them to your charts.

If you still feel good about your case, go to the next step. If you see that your practice made glaring omissions, take your lumps and repay the insurer. After all, your participation agreement with a payer invariably says you will follow the guidelines in effect when the service is delivered.

Adjust your documentation to avoid recoupment

While you can’t modify charts (especially when the patient exam occurred 18 months ago like in our example), you can make changes to your chart documentation moving forward. Use current payer requirements (Local Coverage Determinations, Local Coverage Articles, etc.) to construct your EMR templates or paper documentation to match or “parrot” the payer polices. This makes it easy for the payers to agree that your documentation meets their policy. You may even choose to take what a couple of payers have in their policy and make your template that way. This helps moving forward, but you still have to deal with the issue of the payer demand for recoupment.

3. Draft a rebuttal letter.

Write a separate letter for each date of service on every patient. Construct your arguments carefully so as to meet every issue head-on. For example, if the payer says you must have an ADL document to support cataract surgery, call attention to it in your rebuttal. Address each of the policy requirements in your letter, and point out the place in the chart the information is located. That often means including the page number and even quoting from the chart notes in your letter. Include a complete abbreviation list and a signature log with your packet. The clearer you make it in your letter and chart, the easier it is for the payer to agree with you and reverse its opinion that you owe money back.

Ask someone else in your office familiar with documentation and coverage to read over your materials. Request that this person be critical and make suggestions and relevant changes.

4. Get the information to the payer.

Follow the instructions precisely. For example, the address to send your rebuttal to the payer might be different than the one on the letter. Other tips include the following:

  • If sending paper, make a copy and put it aside. Send via a method that has tracking and requires a signature.
  • If sending electronically, do so via a secure method.
  • Make an electronic copy of exactly what you send.
  • Don’t fax due to the loss of resolution.
  • Pack paper securely (double-bag, waterproof, etc.).
  • Get a “delivery receipt” as well as a “read receipt” you send it via email. Print these e-receipts and save them with your assembled files.

5. Wait.

Hopefully, the insurer will view your arguments favorably and rescind its previous decision. It’s possible the insurer still denies but bring forth another argument in support of its stance. Any letter back from the insurer will note when and where to direct further higher-level appeals.

Conclusion

Payers sometimes ask for payment back from you — most often, because they believe you did not follow their policy or they cannot properly interpret your documentation. Evaluate your documentation, and decide whether changes are in order moving forward. Follow all payer instructions and timelines faithfully, and keep careful records of all phone, postal, and telephone conversations. OP