Speaking the Same Language as the Payer

By Denise Wilson | October 29, 2019

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. Reading The Centers for Medicare and Medicaid Services (CMS) regulations on payment policies can be overwhelming, let alone trying to understand how commercial insurers operate. Yet, the importance of understanding payer language in denial and appeal management is crucial.

Think of the appeal process as a conversation between provider and payer. It may not be an efficient or effective form of communication, to be sure, but it’s what we have to work with today.

The payer reviews submitted payments and medical record documentation and lets the provider know if payment is warranted. If the payer believes payment is not warranted, the payer issues a denial, often in written or electronic form. The denial includes an explanation of why a payment was not warranted. Sometimes the explanations are written in clear, simple language. But, more often than not, the explanations are written in payer-speak, including references to payment and billing codes.

The provider has an opportunity to appeal a denial with arguments on why the patient encounter should be reimbursed as billed.

Next, the payer reviews the provider’s argument in the form of an appeal letter (or sometimes a verbal discussion ensues) and decides again if they believe payment or partial payment is warranted. In most instances, if the denial is upheld (not overturned in favor of the provider), the provider is allowed to appeal again, and so on.

Paying close attention to this conversation allows the appeal writer to learn a lot about how to structure appeal arguments in the future. Understanding the payer’s language is vital to structuring winning appeal arguments.

An example of using the payer’s language would be if a payer states 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 about how there was, indeed, an attempt at conservative therapies prior to surgery and then demonstrate the documentation in the medical record and explain why the conservative therapies failed.

Using the payer denial language in the appeal makes it very clear to the reader which denial reasons the provider is challenging. Refute each reason for denial with clear and specific detail. Use the payer’s denial language to structure the appeal arguments, and the appeal conversation will be easier to manage and more successful for the provider.