Why You Should Include Payer Payment Guidelines in Appeal Templates

Including payer payment guidelines in your appeal letter templates can increase the efficiency and effectiveness of your appeal writing. Most payers develop and publish very specific payment guidelines for medical and surgical procedures. This ensures payment is made only for services that are medically necessary to effectively treat a person in a medically effective but also fiscally responsible (read least expensive) way. CMS publishes these payment guidelines as National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs). Commercial payers often times publish their payment guidelines as Clinical Policy Bulletins (CPB), Medical Policies, or other similar titles. It’s generally easy to find these guidelines on the Internet. CMS has a Medicare Coverage Database (MCD) that can be accessed at http://www.cms.gov/medicare-coverage-database/. You can find both NCDs and LCDs there. Most commercial payers publish their CPBs in the Provider area of their public websites. You must also consider if your provider organization is contracted with the payer and whether there are additional coverage policies that may apply.

When reviewing an NCD, LCD, or CPB, pay particular attention to the sections that spell out the following:

  • Coverage Indications
  • Limitations and/or Medical Necessity of the Service
  • Documentation Required for Payment of Services
  • Covered ICD-9
  • Billing Codes

The guideline may require supporting lab results, radiology reports, therapy records or a listing of current medications. These may need to be obtained from the files of another provider. When developing a template for a particular medical or surgical procedure, it’s easy to include the list of medical necessity requirements and required documentation in the template. In fact, these can be included in such a way that the appeal writer can use them as a checklist of sorts to argue that all required documentation is present in the medical record. In some instances, you can give a reason for why particular documentation is not included. For example, explaining why a patient who was unable to tolerate a certain drug regimen prior to advising him to move ahead with surgery. In this way the appeal writer does not have to research the payment policies or guidelines for surgeries or procedures. Rather they can simply compare those guidelines embedded in the appeal letter to the documentation in the medical record. Even if the denial or the given reason for the pre-payment audit is one specific issue—such as a trial of conservative care before surgery—including all of the payment requirements in the appeal letter template allows the appeal writer to assure the auditor that all requirements are met. That helps prevent a second denial for a different payment requirement.

The final piece of the appeal is to build the roadmap between payment requirements and the medical record. Make it as easy as possible for the auditor or reviewer to rule in your favor by citing specific page numbers of the medical record where the required documentation can be found. If the appeal writer can point the reviewer to the exact documentation in the medical record that supports the medical necessity of services provided, the reviewer will have a much easier time finding the supporting documentation. Conversely, the reviewer will have a much harder time finding a reason to deny the appeal. Creating the road map can be accomplished in a variety of ways, but in its simplest form, a road map is a citation of the name of the document and the page number of the medical record where the documentation referenced in the appeal argument can be found.

How are you incorporating payer payment guidelines in your appeal letter templates?