The Triad of the Appeals Team

By Denise Wilson | October 29, 2019

Which knowledge area in appeal writing is the most important? Is it knowledge of the payer, knowledge of the field of medicine concerning the denial, or is it knowledge of the hospital and the organization of the medical record (especially for appeal writers who write appeals for groups of hospitals)?

Most clinicians might answer that knowledge of the area of medicine concerning the denial is the most crucial element in medical necessity appeal writing. Clinicians may feel they are at their most comfortable and most effective state when appealing a denial that mirrors their clinical background. There is no substitute for actual clinical experience. As a clinician reads through the medical record, a picture begins to form of how sick the patient was, what the patient’s current needs and potential problems might be, and how long it might take to resolve their present illness.

Granted, a well-designed appeal letter template, through the inclusion of standards of medical care in the template, will help guide the appeal writer to a compelling argument for medical necessity around any diagnosis or procedure. An appeal letter template can equip a writer to write a persuasive argument for the medical necessity of services provided, even when the writer lacks experience in a particular area of medicine. Any doubts a writer may have about a specific standard of care should be discussed with another clinician with expertise in that area.

What about the other two areas of the triad? A well-written appeal argument does no one any good if it doesn’t get to the payer on time, at the correct address, and accompanied by appropriate and required information. Having individuals on the appeals team who have intimate knowledge of the payers and their appeal, external review, and dispute resolution processes is critical. That individual should have exceptional organizational skills as well as a winning disposition to create a trustworthy and mutually respectful relationship between the payer and the provider.

Finally, the medical record organization itself is an essential piece of the appeal process. Familiarity with the structure of the medical record certainly makes for quick and efficient work in appeal writing. Think about how an appeal writer accesses a medical record while writing an appeal. Is the medical record produced for the appeal writer in a form that is “auditor friendly” and thus, “appeal writer-friendly”? Is the medical record complete, well organized, tabbed, and page numbered, without pages and pages of redundant information? Does the appeal writer see and access the medical record in the same way the payer who receives the appeal letter will see and access the medical record? A poorly produced medical record will increase frustrations for the appeal writer while decreasing the efficiency and effectiveness of the appeal argument.

For the greatest success, consider all aspects of the triad when assigning appeal work to the appeal writing team. Matching denials to team members who have the clinical, payer, and medical record expertise to write a winning argument will improve your success in overturning denials.