For a new appeal writer, learning the language of health insurance can be daunting, especially if one’s background is clinical and not business oriented. I remember as a newbie reading the CMS regulations on payment policies over and over again. I’d  tease out every nuance of what was written and follow every reference down every rabbit hole until I finally gained a working knowledge of the system. I doubt I’m alone here.

Think of the appeal process as a conversation between provider and payer. Maybe not the easiest and smoothest of conversations, to be sure, but it’s what we have to work with today.

  1. The payer reviews your payments and documentation and lets you know what they don’t like about it in the form of denied payment. If you’re really lucky, they’ll even give you a bit of explanation of why they don’t like it.
  2. The provider then appeals it with arguments on why the patient encounter should be reimbursed as billed.
  3. Next, the payer let’s you know they don’t agree, and so forth.

If you pay close attention to this conversation you can learn a lot about how to structure your arguments in the future.

Using Payer Language to Win Appeals

One very important element of this conversation is the practice of speaking the same language as the payer. I am referring to when the payer claims payment will not be made because the services provided were not reasonable or medically necessary. The appeal language should include an argument that the services provided were indeed reasonable and medically necessary and then expalining why.

A payer may state the knee replacement surgery was not medically necessary because there was no reasonable attempt at conservative therapies prior to the surgery. The appeal language should include an argument how there was indeed an attempt at conservative therapies and then show where those attempts are documented and why they failed.

Using the payer denial language in your appeal makes it very clear to the reader which reasons for denial are being refuted. Of course, you want to refute each and every reason for denial with clear and specific detail. So, use their own denial language to structure your appeal arguments and you’ll find the conversation easier to manage and more successful for the provider.

What elements of payer language are you struggling to understand?