Appeals Process for Challenging High-Stakes Claims

This article is focused on high-stakes claims appeals of the utmost difficulty, rather than the routine process. In rheumatology, such high stakes inherently will always entail a buy-and-bill specialty medication, such as a biologic or hyaluronan; to our newer colleagues, those medications are normally billed as J codes. It only takes one instance of nonpayment to nullify any and all profit for many injections or infusions of the respective medication. Therefore, it is critical to do everything you can to have a bulletproof basis for a claim that should not be denied or require an appeal.

Be Proactive to Avoid Problems and Reduce Complexity of Appeals

A free benefits investigation form from a manufacturer’s hotline can play a central role in supporting your claim and guiding you through what the payer needs or wants for appeals. Payer information that may be wrong or incomplete will be recorded by this third-party benefits service; these errors work to your benefit and to the payer’s detriment.

Obtain all necessary prior authorizations, but also try to require the payer to stipulate prior authorization approval even when it is not mandated, or specify the acceptance of prior notification. You are extending a type of credit to patients insofar as you must trust them that coverage has not or is not ending for any reason. Therefore, it is important to re-verify that benefits are in place for the services. An unreliable person cannot justify risking funds, permanently losing resources, or reducing staff benefits and patient care resources—it is not ethical.

For the prior authorization process, you can (and really should) add the term “Predetermination” to the heading or title; this can be done at no cost. Coupling this with your stipulation of all Current Procedural Terminology codes means this payer’s approval entails previous acknowledgment of medical necessity. That is as secure as you can get in terms of having a commitment to pay, despite lawyers’ clauses that it is not.

I add the term “Fraud Alert” to prior authorizations for hyaluronan because a plan famously denies claims for this drug after approving and stipulating agreement to all of the above. By doing so, I am letting this plan know that I will file a jurisdictional complaint if a denial occurs. Because physicians or pharmacists who see this warning may have to worry about licensing board issues if they are reported, the odds of receiving illicit denials, which are common, are reduced.

Avoid having to correct your coding by keeping miscoding to a minimum. A necessary correction can be submitted, but your error may be used as an excuse to call it a “Duplicate Claim,” and to serially mishandle your submission. Using the benefits investigation form to track everything—in addition to keeping your own records—is key to escalating a serial denial problem.

Strategies for Escalating or Arbitrating Denied Appeals

Quickly escalate and refer to your follow-up claims as First or Second Level of Appeal, when appropriate. Your jurisdictional complaint cannot typically be addressed without denial of a Second Level of Appeal.

Jurisdictional complaints go to government-based authorities that have designated oversight of the broadest program under which your respective payer and plan is operating. They often have prosecutorial authority, knowledge, and resources that can be used to levy fines and penalties, licensing restrictions, and consent decrees.

The government-based authority for Medicare-based plans is the Centers for Medicare & Medicaid Services (CMS). Complaints to CMS escalate to the Office of Inspector General. However, because this article is primarily about commercial payers, I am talking about states’ departments of insurance for fully funded and traditional insurance, and the US Department of Labor (USDOL) for employer-sponsored plans.

Teachers in municipalities in Texas and other states are typically under state government authority. Therefore, for the Teacher Retirement System in Texas, I can submit an illicit case through my Texas State Senate Representative, who is on the state Health and Human Services Committee. I did this and received the fastest, most effective case work I have witnessed in 20 years. Spe­cifically, my assertion that it violates the standard of care to have short (months instead of years) expiration for on-label treatment of Crohn’s disease with infliximab was upheld, and Aetna asserted that it would discontinue such practices broadly. The basis of the denial was thus removed, payment was completed, and thousands of beneficiaries were protected in greater measure.

The USDOL does not relish case work for physicians’ offices. They will reluctantly process queries if the documentation is strong and clearly organized, and if it includes the requisite “Assignment of Benefits” signature of the patient or member. The local or district division of the USDOL is called the Employee Benefits Security Administration (EBSA), for which your initial contact should be via facsimile. However, when this agency no-bills valid complaints, I submit my cases to the USDOL Office of Inspector General hotline, at which point my complaint is partially against the EBSA itself for gross malfeasance or worse. This latter step, to be sure, is a drastic escalation.

I follow up with documents earmarked “Established Case” that I fax open-copied to the insurance plan about which I am complaining. This approach may lead to a case being cleared simply because of the scare factor, as no one wants to get caught in citable offenses, which is precisely what I am talking about. For example, if EBSA helps you, their first step is to call the benefits department of the employer. The employer’s caller identification shows up as USDOL, and an attitude of cooperation to do the right thing and to avoid a “Denial of Benefit” citation is engaged.

Licensing boards for nurses, physicians, and pharmacists can be reached by filling out a complaint form from the respective board. It is key to submit the names of reviewers for an insurance plan that is violating the standard of care and breaching licensing standards of the healthcare policy. I first successfully did this approximately 15 years ago with an illicit audit that held all funding for infliximab with no basis and 100% validation of claims.

Nonjurisdictional file copies of a complaint can be valuable if filed with the necessary HIPAA business associate agreement; this should be secondary to escalating your claims, as I described earlier in this article. These copies can go to colleges or societies, such as the American College of Rheumatology or the state medical society. Resolution is better than no resolution, but funding one claim pales in comparison to the triggering of program-wide protections that ensue under risk for significant penalties.

It is even more concerning when a massive short-funding agenda is recognized by my colleagues but not reported jurisdictionally, as this protects serious offenses and ensures that they will continue. An infusion foundation helped rheumatology practices get a payer to correct their billing system for rituximab with no penalty for massively short funding nationwide, and caused a loss of therapy for thousands of patients. Being nice can be highly destructive when the entire cost of correcting the payer is borne by the providers and patients. Fees, penalties, and interest may have prevented or reduced very similar abuses from recurring.

In conclusion, I encourage my colleagues to look with fresh eyes at the compelling need to escalate at least a few select cases from time to time. Such advocacy is therapeutic and is ethically essential to ensure standard of care, access to care, and maintenance of healthcare resources, which are necessary for the continuation of vital life-saving services.