Don’t take no for an answer: Write an appeal letter

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 about how hospitals are using contract law to get reimbursement denials reversed.

"We don’t seem to be having as much luck [with appeal letters]," Smith says. "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 a sample appeal letter, 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 staff in your hospital’s managed care department, who can refer to the provider manual or contract. If information on the appeals process and addresses is not available or 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. 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.

Sample Letter

[Insert Proper Insurer’s Address Here]

APPEAL

RE: Patient:
I.D. #
Insurer:
Provider:
Dates of Service:
Total Charges:
Our File No.:

Dear Sir/Madam:

It is my understanding that [insurer’s name] denied this claim on the basis that the services were not authorized. We disagree with this determination and request that you consider the following:

Upon admission, the patient presented to [hospital] without any insurance information. It was subsequently determined that the patient was covered by [insurer]. The provider contacted [insurer] and the patient’s admission was authorized by Amy at [phone number] with authorization number 1263628.

Under California law, because this patient’s services were authorized, [insurer] cannot now deny payment to the hospital for these charges. Specifically, Cal. Health & Safety Code §1371.8 (1994) provides that a health care service plan that authorizes or approves medical treatment by a provider shall not rescind or modify that authorization after the provider renders the services.

Furthermore, the services provided to this patient were rendered on an emergency basis. Cal. Health & Safety Code §1371.4(b)(1994) requires a health care service plan to reimburse a provider for emergency services rendered to an insured. Additionally, Cal. Health & Safety Code §1371.4(c)(1994) provides that a health care provider is not required to obtain pre-authorization or approval from a health care service plan in order to obtain reimbursement for emergency services.

Moreover, the services rendered to this patient were medically necessary. [Insert specific details supporting the medical necessity of the admission].

In light of the fact that the services provided to this patient were authorized, emergent in nature, and medically necessary, we request that you reconsider this claim for payment. Should you intend to deny this claim, please advise as to all grounds for your denial. Also, please provide all documentation in support of your denial, as well as a listing of the administrative and appeals procedures that we must exhaust.

To assist you in your review, I have enclosed the UB-92 form and the medical records. Should you have any questions or need additional information, I can be reached at [phone number].

I will look forward to a response from you within twenty (20) days of the date of this letter. Thank you for your help in resolving this matter.