Denise Wilson | October 28, 2019
There is never a reason to write an appeal letter from scratch unless you are writing your very first appeal on a particular denial type. You will never write just one appeal for chest pain or knee replacement surgery. Denials come in multiples. The only difference from the first chest pain denial and the twentieth is the circumstances of the patient.
Evidence-based guidelines (EBGs), as used in the context of this article, are typically peer-reviewed journal articles that support the standards of care in the medical community. These guidelines help describe scientifically studied and sound reasons for the treatment of persons with certain medical conditions. EBGs can help define when a patient requires an intense level of services that can be provided only in a hospital setting, or when specific medical or surgical treatments or cures are most appropriate for a given condition.
EBGs don’t change from patient to patient. While the standards of care may change over time, they do not change based on the patient or the patient’s choice of medical insurer. Having EBGs already embedded in an appeal letter template saves the appeal writer time, effort, and frustration when arguing that the care provided was according to generally accepted medical standards of care.
Further, a successful appeal letter template includes:
The patient narrative
Arguments around medical necessity
Coding criteria, when appropriate
Regulatory or payment citations
An explicit request for payment as appropriate
Any other information that leads to a compelling argument for payment
Creating appeal letter templates is not an easy task. It is time-consuming and requires research and experience in appeal writing. Creating an appeal letter template library is work that has a beginning but never an end. Templates must be reviewed, updated, edited, appended, and adjusted to maintain the relevance and effectiveness of the arguments. Yet, having an appeal letter template library is so worth it. The time and effort you can save in the work of appeal writing is invaluable.
Begin with the most frequently denied issues. These are typically short-stay inpatient admissions that enter through the ED: chest pain, syncope, heart failure, TIA. What arguments have been successful in overturning these denials? Start with a letter that was successful and go from there. Research the standards of care in the medical community and include that in your template. Just use the three or four sentences from evidence-based medicine that support the medical necessity of admission or procedure. Do that for every new issue that comes across your desk, and eventually, you will have built a library of resources.
An appeal template library can transform your work from overwhelming to winning.
