Creating The Narrative

The Narrative

Every appeal letter includes a narrative that tells the patient’s story. The narrative explains why the
claim submitted for the services provided to the patient should have been paid as billed. The narrative is
the most significant part of the appeal letter. The narrative offers the writer the opportunity to deliver a
persuasive argument for appropriate payment by crafting a compelling, but truthful, story of the
patient’s medical episode. The narrative can be made compelling in several ways. Referring to the
patient by name helps put flesh on the patient and bring them to life for the reader. Citing abnormal
exam and lab findings while ignoring the normals emphasizes the seriousness of the patient’s condition.
Explaining the relevance of signs, symptoms, assessment, and test results connects the medical record
documentation to the significance of the patient’s illness and risk of injury, harm, or death without
appropriate medical care. Using a bold font judiciously helps direct the attention of the reader to the
most critical information and events in the medical record.
In the case of level of care appeals, the narrative tells why the services provided were billed
appropriately as inpatient services rather than outpatient services. The narrative directly refutes
incorrect statements in the payer’s decision to deny inpatient payment; if the payer has provided a
denial notice with an explanation of the denial reason. Sometimes the denial notice includes only a
reason code such as Reason Code 50: Not Medically Necessary, without further detail on why the payer
considers the services billed as not medically necessary.
Content
The narrative in a level of care appeal includes certain content such as:
medical history,
family history when appropriate,
presenting signs and symptoms,
physician office, prior treating hospital, or emergency department (ED) assessments, testing, test
results, treatments and response to treatment,
the decision to admit to an inpatient setting,
the relevant hospital course with emphasis on documentation in the record that supports the inpatient
setting; and,
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a direct disproving of the payer’s incorrect statements regarding the reason for the denial or
underpayment.
Flow
The narrative should flow logically and chronologically. However, for claims paid on a DRG, the narrative
does not need to be a day by day review of the patient’s stay. A daily summary of the patient’s stay may
be necessary for arguing denied per diem days.
Start the narrative by clearly stating the facts of the denial and the reason for the appeal. For example:
“PayerABC denied inpatient payment for John Doe’s hospitalization at Memorial Hospital
from December 8, 2019, through December 12, 2019. PayerABC claims that an inpatient
setting was not reasonable or medically necessary to treat Mr. Doe and that care could
have been provided in an outpatient setting. This letter represents a request for an appeal
for inpatient payment with substantiation of the medical necessity that supports the need
for services as provided and billed.”
It can be helpful to use the name of the level of appeal assigned by the payer. Payers may refer to the
first level of appeal as redetermination or reconsideration. For clarity, the appeal writer should use the
words redetermination or reconsideration in place of the word appeal.
Begin with a brief introduction of the patient, patient’s age, disabilities, living conditions, and family
history, if pertinent. Refer to the patient by name. Use the terms lady or gentleman instead of
beneficiary or patient to bring the patient to life for the reader.
Describe the patient’s presenting signs and symptoms, whether documented in the referring physician’s
office notes, the transferring hospital’s records, or the ED. A best practice is to focus on the abnormal
findings and ignore the normal findings. Presenting only the abnormal findings keeps the appeal
argument focused on the reason for the inpatient admission while avoiding clutter that does not add to
the argument.
Abnormal lab findings should be documented as the value, followed by the letter H, L, or C in
parenthesis to indicate high, low, or critical value. Follow that with the normal lab value range in square
brackets. Example, Potassium 6.0 (C) [3.5-5.5]. This format helps readers without a strong clinical
background, such as administrative law judges, understand the gravity of the abnormalities. Omitting
the value descriptors such as mg/dl helps eliminate clutter in the letter improving readability.
The ED physician’s presumed diagnosis can help support the reason for admission. Patients who leave
the ED with a confirmed or strongly suspected diagnosis are generally more appropriate for an inpatient
setting. Patients admitted to rule out, monitor, or further evaluate their condition are less likely to be
seen by payers as appropriate for inpatient admission.
Persuasion
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The narrative should be persuasive in influencing the payer to reverse the decision to deny or reduce
payment for the inpatient stay. The narrative should provide critical analysis of the presenting and
developing signs and symptoms observed in the patient. Include a discussion of the risks for an adverse
event or worsening of symptomology in the absence of immediate and intense care provided in a
hospital setting. Tell the payer why care in an outpatient setting would not be successful or appropriate
for the patient’s condition, especially if outpatient treatment had already been attempted and failed.
Don’t expect that the payer will perceive the seriousness of the patient’s illness or the risk of adverse
events based on a list of signs, symptoms, tests, and exams. Explain to the payer the significance and
severity of the abnormalities documented in the medical record.
Standards of Care
Every payer publishes a definition of the medical necessity or appropriateness of inpatient admission.
Regardless of payer, the definitions always rely in part on what is considered the standard of care in the
medical community. It is the job of the appeal writer to connect the dots between the patient’s
presentation and the standard of care. Interpret the facts and information in the medical record in a
way that drives the payer to a decision to pay the claim when appropriately billed. References to
standards of care can be included in the narrative or listed in another part of the appeal letter. A
compelling argument draws a direct line between the patient’s condition and the need for inpatient
admission, critical care, intense medical services, risk of adverse events including morbidity or mortality,
or greater than two midnights of hospital care as recommended and published by medical experts in the
healthcare community. Use quotations from reputable published standards of care that support the
need for hospital care. Cite the published literature using a recognized format such as APA and include
the URL to the article.
Finishing Touches
When traditional Medicare is the payer, note the dates and times of the patient’s presentation to the
hospital, the admission order, and the effectuation of the discharge. Since the Centers for Medicare and
Medicaid Services defines an inpatient based on the number of midnights the patient requires hospital
care, among other things, it’s important to include dates and times of the events related to the
hospitalization.
Use a bold font or underlining to highlight the critical aspects of the patient’s story so that if the reader
does nothing but skim the appeal letter, the information in bold should be enough to persuade the
reader to overturn the denial. Use bold or underline sparingly. The reader will tend to ignore bold or
underline when there is too much of it.
Finish the narrative with a summary of the facts regarding the admission. Provide rationale that
supports the facts. Explain why the patient required care that could only be provided in an inpatient
hospital setting. Be sure to reiterate the expectation of the outcome of the appeal, such as: “Memorial
Hospital provided medically necessary services to John Doe with the expectation that those services
would be reimbursed according to the documentation in all payer communications. Memorial Hospital
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requests that you reconsider this claim and require payment to be made to Memorial Hospital for the
services provided to John Doe as originally billed.”