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Appealing Denied Claims FAQ

  • Has ACEP developed sample letters for appealing claims?
    Recommendations
    Answer

    Yes, the ACEP Reimbursement and Coding and Nomenclature Advisory Committees have identified the most common reasons that payers inappropriately deny or underpay ED claims. A series of sample letters has been prepared to assist your billing service in appealing these claims, including:

    • Bundling Separately Reportable Procedures with Critical Care Service (CPT codes 99291-99292)
    • Assignment of Benefits Denial
    • Concurrent Care Denial
    • Critical Care Service Denied (CPT code 99291)
    • Downcoding of E/M Services Based on ICD-9 Diagnostic Code
    • Incorrect Coding Audits
    • Lack of Recognition of CPT Modifier 25
    • Bundling CPR (CPT code 92950) with ED E/M Services (CPT codes 99281 – 99285)
    • Bundling Splints (CPT codes 29105-29130 and 29505-29515) with ED E/M Services (CPT codes 99281-99285)
    • Medicare Carrier X-Ray/ECG Interpretation Denial
    • Non-Medicare X-Ray/ECG Interpretation Bundled into ED E/M Code (CPT codes 99281-99285)
    • Services Denied Based on ICD-9 Codes

    These sample letters can be accessed at:

    https://www.acep.org/administration/reimbursement/templated-letters-for-appealing-denied-claims/templated-letters-for-appealing-denied-claims/

    Answer

    Yes, the ACEP Reimbursement and Coding and Nomenclature Advisory Committees have identified the most common reasons that payers inappropriately deny or underpay ED claims. A series of sample letters has been prepared to assist your billing service in appealing these claims, including:

    • Bundling Separately Reportable Procedures with Critical Care Service (CPT codes 99291-99292)
    • Assignment of Benefits Denial
    • Concurrent Care Denial
    • Critical Care Service Denied (CPT code 99291)
    • Downcoding of E/M Services Based on ICD-9 Diagnostic Code
    • Incorrect Coding Audits
    • Lack of Recognition of CPT Modifier 25
    • Bundling CPR (CPT code 92950) with ED E/M Services (CPT codes 99281 – 99285)
    • Bundling Splints (CPT codes 29105-29130 and 29505-29515) with ED E/M Services (CPT codes 99281-99285)
    • Medicare Carrier X-Ray/ECG Interpretation Denial
    • Non-Medicare X-Ray/ECG Interpretation Bundled into ED E/M Code (CPT codes 99281-99285)
    • Services Denied Based on ICD-9 Codes

    These sample letters can be accessed at:

    https://www.acep.org/administration/reimbursement/templated-letters-for-appealing-denied-claims/templated-letters-for-appealing-denied-claims/

  • Should our billing service appeal claim denials, procedure code bundling and/or claim adjudication statements that the CPT codes are "incidental," "mutually exclusive" to other codes or "integral procedures?"
    Recommendations
    Answer

    Yes, it is important to appeal all incorrect payments (e.g. downcoding, inappropriate bundling) and unpaid claims (e.g. "non-covered service") in a timely fashion (less than 30 days). Appealing claims can result in substantial recovery of otherwise lost revenues and may result in positive changes in the way the payer treats subsequent claims. 

    Before an appeal is filed, any claims that have been downcoded or bundled should be reviewed by the billing agent to ensure that the claims were appropriately coded in the first place.  It is important to be aware of and to incorporate into the appeal any contract terms and/or government regulations that may clarify or validate the basis of the appeal. 

    An appeal to the insurer may be required by the state as a precondition to later appealing or lodging complaints with state regulatory agencies.  The validity of your appeal may also enhance your chances of recovering underpayment in court if that avenue becomes necessary.

    Answer

    Yes, it is important to appeal all incorrect payments (e.g. downcoding, inappropriate bundling) and unpaid claims (e.g. "non-covered service") in a timely fashion (less than 30 days). Appealing claims can result in substantial recovery of otherwise lost revenues and may result in positive changes in the way the payer treats subsequent claims. 

    Before an appeal is filed, any claims that have been downcoded or bundled should be reviewed by the billing agent to ensure that the claims were appropriately coded in the first place.  It is important to be aware of and to incorporate into the appeal any contract terms and/or government regulations that may clarify or validate the basis of the appeal. 

    An appeal to the insurer may be required by the state as a precondition to later appealing or lodging complaints with state regulatory agencies.  The validity of your appeal may also enhance your chances of recovering underpayment in court if that avenue becomes necessary.

  • What is the best method for communicating with payers about appeals?
    Recommendations
    Answer

    The most efficient method for appealing claims is to obtain direct internet access to the claims departments of the payers. This is particularly true with larger payers.  Otherwise, it is helpful to identify and establish key contacts at the payers by telephone or email. Rather than submit multiple single case appeals, it is sometimes helpful to appeal underpayments by collecting multiple claims treated in the same fashion by the payer and submitting these similar disputes to the payer in grouped appeals. Not only is this more efficient, it facilitates identification of patterns of inappropriate claims payment. Persistent patterns of inappropriate claims management should be brought to the attention of state health plan regulators.  It also may be important to discuss either non-payment of CPT codes (e.g., moderate sedation codes), payer "bundling" policies, and non-payment of 12 lead ECGs (e.g., CPT 93010) with state ACEP chapters for the purpose of petitioning the payers to request changes in payer policies. Claims underpayment may also be successfully addressed in small claims court.  Large collections of underpaid claims may be taken to superior court for adjudication.

    If a payer is subcontracted to a health plan and is accessing the plan's contracted rates with the provider, but is inappropriately paying claims, it may be useful to contact the health plan directly to complain about the claims payment behavior by the subcontractor or the 'plan associate'.

    Answer

    The most efficient method for appealing claims is to obtain direct internet access to the claims departments of the payers. This is particularly true with larger payers.  Otherwise, it is helpful to identify and establish key contacts at the payers by telephone or email. Rather than submit multiple single case appeals, it is sometimes helpful to appeal underpayments by collecting multiple claims treated in the same fashion by the payer and submitting these similar disputes to the payer in grouped appeals. Not only is this more efficient, it facilitates identification of patterns of inappropriate claims payment. Persistent patterns of inappropriate claims management should be brought to the attention of state health plan regulators.  It also may be important to discuss either non-payment of CPT codes (e.g., moderate sedation codes), payer "bundling" policies, and non-payment of 12 lead ECGs (e.g., CPT 93010) with state ACEP chapters for the purpose of petitioning the payers to request changes in payer policies. Claims underpayment may also be successfully addressed in small claims court.  Large collections of underpaid claims may be taken to superior court for adjudication.

    If a payer is subcontracted to a health plan and is accessing the plan's contracted rates with the provider, but is inappropriately paying claims, it may be useful to contact the health plan directly to complain about the claims payment behavior by the subcontractor or the 'plan associate'.

  • When can I balance bill the patient for the inappropriate unpaid portion of the bill?
    Recommendations
    Answer

    Usually, the term "balance bill" is reserved for situations where the non-contracted physician attempts to receive the total actual charge for a patient service when the physician has not received full payment from the payer. The responsible party is ultimately the patient when the physician bills for the difference between billed charges and payment made directly to the physician by the payer. Because not all states allow a non-contracted physician to bill the patient for insufficient payment, you should check the government regulations regarding balance billing that apply in the region or state where the services were provided.

    If balance billing is allowed in your state, it may be helpful to simultaneously dispute the underpaid claim (on behalf of the patient) and bill the patient for the unpaid portion of the claim. This puts the patient on notice that a dispute has been filed on their behalf with the payer; however, the patient is ultimately responsible for payment.  It may also be helpful to outline for the patient how they may assist in the resolution of the dispute by directly contacting their healthcare plan.

    Separately, you are always able to bill a patient for any traditional patient-responsible payments like copays and deductibles.

    Answer

    Usually, the term "balance bill" is reserved for situations where the non-contracted physician attempts to receive the total actual charge for a patient service when the physician has not received full payment from the payer. The responsible party is ultimately the patient when the physician bills for the difference between billed charges and payment made directly to the physician by the payer. Because not all states allow a non-contracted physician to bill the patient for insufficient payment, you should check the government regulations regarding balance billing that apply in the region or state where the services were provided.

    If balance billing is allowed in your state, it may be helpful to simultaneously dispute the underpaid claim (on behalf of the patient) and bill the patient for the unpaid portion of the claim. This puts the patient on notice that a dispute has been filed on their behalf with the payer; however, the patient is ultimately responsible for payment.  It may also be helpful to outline for the patient how they may assist in the resolution of the dispute by directly contacting their healthcare plan.

    Separately, you are always able to bill a patient for any traditional patient-responsible payments like copays and deductibles.

Updated February 2021

Disclaimer

The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only.   The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date.

The FAQs and Pearls are provided "as is" without warranty of any kind, either express or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Specific coding or payment related issues should be directed to the payer.

For information about this FAQ/Pearl, or to provide feedback, please contact David A. McKenzie, ACEP Reimbursement Director at (469) 499-0133 or dmckenzie@acep.org.

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