The Triad of the Appeals Team

When I teach appeal writing, I like to ask the group this question, “Which knowledge area in appeal writing is the most important? Is it knowledge of the payer, knowledge of the area of medicine concerning the denial, or is it knowledge of the hospital and the organization of the medical record (especially for appeal writers who write appeals for a group of hospitals)?”

As a clinician, for me, the answer is the knowledge of the area of medicine concerning the denial. I know I am most comfortable and happiest when a denial in my queue of assigned appeal work involves a cardiac or pulmonary diagnosis which mirrors my clinical background.

How Appeal Letter Templates Help You Win

Now, granted, a well designed appeal letter template will help guide the appeal writer to a very strong argument for medical necessity around any diagnosis or procedure by including standards of medical care. An appeal letter template can equip a writer to write a very strong argument for the need for major joint replacement surgery by comparing the required documentation elements already present in the appeal template to the documentation in the medical record. I am also not proposing that you must always match up the clinical issue with a clinician who has experience in that area. That would be impossible for most organizations. Who has that many appeal writers on hand?

Building a Winning Team

There is no substitute for actual clinical experience. I find that I can picture those cardiac and pulmonary patients whose services were denied payment because I have actually cared for similar patients in the past. As I read their histories and physicals, my mind begins to formulate how sick they are, what their needs and potential problems might be and how long it might take to resolve their current illness.

What about the other two areas of the triad? A well written appeal argument does no one any good if it doesn’t get to the payer on time, at the correct address and accompanied by appropriate and required information. Having an individual on your team who has intimate knowledge of the payers and their appeal, external review and dispute resolution processes is critical. That individual should have exceptional organizational skills as well as a winning disposition to create a solid and mutually respectful relationship between the payer and the provider.

The Medical Record

Finally, the medical record itself is a very important piece of the appeal process. Very often the response to the question posed at the start of this blog is that familiarity with the medical record is very important in appeal work. Familiarity with the structure of the medical record certainly makes for quick and efficient work in appeal writing. And, it doesn’t hurt if a writer becomes familiar enough with a care provider’s scribbling to actually make out what was written in the record. Is the provider producing a medical record that is “auditor friendly” and thus, “appeal writer friendly”? Is it complete, well organized, tabbed, page numbered, without pages and pages of redundant information? A poorly produced medical record will increase frustrations while decreasing efficiency and effectiveness of the appeal argument.

So, how would you answer the question posed above? How is your appeal team organized? Are there other important areas that I haven’t considered here?