Writing the appeal letter: First, get the address right

Stick to the point and document

How can we write a more effective appeal letter?

That’s the question posed by Gretchen Smith, MSPH, contract management systems manager at UNC Hospitals in Chapel Hill, NC, after she read the article in the February issue of Hospital Access Management on how hospitals are using contract law to get reimbursement denials reversed.

"We don’t seem to be having as much luck [as the hospitals mentioned in the article]," Smith adds. "Are there certain phrases they’re using? Would it be possible to get a sample copy of an appeal letter?"

In response to Smith’s query, Linda Fotheringill and Malinda Siegel, partners in the Towson, MD, law firm Siegel & Fotheringill, offered the sample appeal letter reproduced below, and these pointers on crafting a more effective letter:

  • Get the address right.

It sounds simplistic, but one of the first things is to make sure the appeal is directed to the appropriate address. In a lot of cases, insurance companies say they’ve never received the appeal, and the excuse can be that it had the wrong address. "Oh, no," they’ll say. "Lack-of-authorization letters go to an address in Tennessee, but medical necessity issues are supposed to go to an address in California."

Getting this right requires coordination with your hospital’s managed care department in knowing what the provider manual or contract says about the appeal process. If it’s unclear, contact provider relations with that payer and get the appropriate information. If the hospital is seeing a pattern of the payer never receiving appeals, consider sending the letters by certified mail.

  • Put a "title" under the address announcing what the letter is.

Is it an appeal, a request for retroactive authorization, a resubmission of a claim? It’s nice to have a title. It can be bold and underlined.

  • Below that, put a caption with the patient’s name, the provider, the member number, dates of service, total charges, and maybe the denial date.

With this, the insurance company can see at a glance what is at issue.

  • Set forth in the first paragraph what you’re doing and why.

After the "Dear Sir or Madam," say, for example, "It is our understanding that charges for the above-captioned patient were denied on the basis of ___." State the problem.

The body of the letter generally will set forth the facts and contract language that dispute the denial and give the hospital’s position on why the claim should be paid.

This is where hospitals get in a little trouble. Sometimes when you tell them to include the pertinent facts, they throw in additional facts that there is no reason to include. Don’t volunteer information. Some appeal writers sort of admit to wrongdoing, as in, "He or she was new on the job that day." Stick to the basic facts that will help get the case paid and don’t include extraneous detail that muddies the waters.

  • After the facts, cite any applicable law that will help you.

Laws vary from state to state, but many have laws related to the provision of emergency services, and laws relating to mothers and babies, among others. In theory, the hospital’s corporate counsel could supply this service, although they often have other things on their plate.

  • Give the medical claim.

If the payer is denying the claim because you didn’t get authorization, you sometimes can turn it around, but you have to give the reason why you didn’t get it and why the services were medically necessary. You must show that had the call been made, the services would have been authorized.

  • In closing, request that the insurance company — if it intends to uphold the denial — provide the hospital with all the appeals the hospital must exhaust on the claim.

Even though you ask, the company may not tell you. You should know the answer yourself by checking the provider manual, which may say, for example that you have 15 days to go to the second level. Keep that in mind, or you might miss the deadline for getting in another letter of appeal. You want to keep your options open.

  • Include any documentation that the payer may need.

This might include a UB-92 form, medical records, or account notes if you need to provide proof that certain things happened. Sometimes the authorization is documented in the records, but send just the parts that document the point you’re trying to make.

  • Remember to follow up on your appeals.

We’ve found that a lot of hospitals have trouble with this. It takes tenacity. Even though you’ve written a beautiful appeal and sent it certified mail, you still need a follow-up system where you call and determine if the payer received it. There are usually laws that require them to respond within a certain time period. You should know that and keep track of it, so you haven’t done the appeal for nothing. (To see sample appeal letter, click here.)

[Editor’s note: Linda Fotheringill can be reached at The Susquehanna Building, 29 W. Susquehanna Ave., Towson, MD 21204. Telephone: (410) 821-5292 or (800) 847-8083. E-mail: sfllc@excite.com.]