Disputing Medicare Advantage (MA) payment denials is a growing challenge for healthcare practices, especially as the number of denials continues to rise due to tighter payer guidelines and increased scrutiny. As denials increase, so do bad debts, while the bottom line decreases. If denials are not addressed promptly and correctly, they can result in significant revenue loss. If approached effectively, practices can create clear processes for revenue cycle teams to address denials and even recover lost income.
Before disputing a denial, the Explanation of Benefits (EOB) or denial letter should be reviewed and cross-referenced to the claim. Practices can most easily resolve technical issues with a corrected claim that may include a new modifier or different code. Strong documentation is crucial if a claim is denied due to medical necessity. A clear narrative should connect the patient’s condition to the services rendered. One should be able to follow the narrative through test results and physician notes.
Below are tips for more successful disputes. If denials or bad debts are getting out of hand, contact Dean Dorton’s Revenue Cycle experts for support.
Tips for Successful Disputes
- Appeal timely: Don’t put off disputing denials—the appeal window is limited, typically 60 days for MA plans.
- Know the payer’s process: Each MA plan has different appeal procedures; follow them exactly.
- Use templates: Create appeal letter templates to standardize responses while customizing clinical details. This approach will save time for teams and allow for a quicker dispute of denied claims.
- Track all correspondence: Keep detailed records of all correspondence. This information may often need to be referred to if the first appeal fails.
- Leverage provider portals: Many payers have online tools to track appeals and upload documentation efficiently.
- Educate your team: Continual training on payer updates, documentation best practices, and billing codes will help to prevent future denials and keep everyone on the same page.
