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ically necessary," an appeal can be successful, especially if accompa-
nied with peer-reviewed studies countering the insurer's denial. Also
keep in mind that flat-out rejections are typically easier to appeal than
reduced reimbursement claims.
When you do appeal, follow the guidelines stated in your provider
agreement. If the patient is a beneficiary of Medicaid or Medicare, you
should carefully consider appeals, as they can be a drawn out and
expensive process. For example, CMS requires a provider to go
through 5 levels of appeal before having a right to bring a claim in
court for non-payment.
For out-of-network providers, the Employee Retirement Income
Security Act (ERISA) governs the vast majority of private insurance
claims. These claims typically require 2 levels of appeal before you
can bring a suit in court. Keep a tight record of your appeals process
in case you do decide to sue later on.
Look for trends
Your denied claim may be a one-off rejection, or it could be part
of a larger problem. Review any claims denials to determine if the
payer has developed a particular policy or guideline that is restricting
payment. Keep in mind that those payment policies could also result
in an insurer's recoupment of previously paid claims.
Here's what tends to happen. CMS will change its payment policy on
a particular procedure and, soon enough, private payers follow.
Oftentimes this is done with very little notice, and providers only
learn of the change when reimbursements on a given CPT code come
to an abrupt halt.
Keep an eye out for these developments, and attempt to clarify the
policy with the insurer if you identify a trend. If you're faced with a
dramatic reduction on your reimbursements for a particular proce-
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