March 1, 2017

Persistence Beyond Initial "No" Wins Appeals

Second in our "How I Won My Appeal" Series

Medical billing professionals work for hours developing effective appeal letters. However, often, the success stories which result from this effort go untold.  At Appeal Solutions, we love to hear your appeal success stories and now plan to pass them along in an ongoing "How I Won My Appeal" series.

As follows is a successful appeal scenario provided by Thomas LaBorde, CPA CIA, Business Manager for LaBorde Therapy Center in Lafayette, LA:

We recently have been appealing a denial for Medical Necessity for about 7 Physical therapy visits. We have been fighting for months and we were at our last level of appeal. We had been denied by 2 external Reviewers. I was browsing through the database to see if I could come up with anything else and found the “Request for Review by Qualified Reviewer.” You see both external reviewers were Internal Medicine.  We sent the letter and requested a review by a Physical Therapist.  Within a week the claims were paid.

Log in to read this full article and to see the appeal letter that The LaBorde Therapy Center used to successfully get their claims paid.

We hope to run one more "How I Won" success story in April. If you have a How I Won My Appeal Success Story, please contact Tammy Tipton at Featured Letters

The appeal letter collection has a number of appeal letters for appealing ICD-10 specificity denials.  With the ICD-10 specificity grace period coming to an end last year, ICD-10 denial are expected to increase. Healthcare billing departments to be on the lookout for denials related to the following Claim Adjustment Reason Codes (CARC) which are likely to be used for ICD-10 denial issues:

  • CO11 - inconsistent with procedure

  • CO16 - claim lacks information

  • CO15 - Authorization Number is missing/invalid

  • CO165 - no refferal

  • CO197 - precert/authorization/notification absent

  • CO198 - precert/authorization exceeded

Don’t let ICD-10 denials become a revenue drain.  Access these resources and many more at

Appeals/Denial Review Time Management Inquiry

Many organizations would like to establish performance metrics for denial management personnel. As a starting point, we are often asked if we have developed or found third party research regarding how many files a denial analyst should be able to work per day.

Unfortunately, we do not have any industry studies involving this question and often end up pointing out the number of variables which impact denial management performance. This challenge was also echoed by comments we received from industry experts who advise other clients.

"That depends upon the type of denial that the person is working. It depends upon the knowledge base of the person working the denial. It depends upon the resources available to the person working that denial. Denials come in a variety of levels and flavors. For example, a state specific type of worker's compensation denial is very different from a Federal worker's compensation denial," said Stephen Killebrew, Claims Analyst for Integrated Human Capital.

"Thresholds depend upon a variety of factors and experience, and time in the chair counts.  A person just entering the field usually is not aware of the scams that take place verses a seasoned person who has sat in the chair 10-15 years and has seen many denial codes and how to quickly resolve them."

We are still collecting comments on this issue in order to put together some best practices for denial management performance metrics.  Please let us know if you have developed quotas for denial management staff, how the quotas were established and if you believe that this measurement impacted performance within the department. Contact Tammy Tipton at to discuss this topic.


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