Rebill or Appeal Denied Claims?

Practices and hospitals can spend years waiting through an appeals process for a denied claim when it might be better to simply rebill it, according to Ralph Wuebker, MD, chief medical officer of Executive Health Resources.

Deciding whether to rebill or appeal a denied claim comes down to a multitude of factors that not only vary facility by facility, but also case by case, Wuebker said at the Healthcare Financial Management Association’s national meeting in Las Vegas.

When deciding the best course of action, organizations should look at the documentation and the time value of money. The average wait time for a case to even be heard during an appeal is 2 to 3 years. Depending on the practice, hospital, or health system’s cash flow and the solvency of the facility, it may not be feasible to wait so long.

“You really start asking yourself, ‘at what point will I accept $8 or $9 instead of $10?’” Wuebker said. “And that’s an individual decision.”

Documentation is also very important, and it can be a determining factor between whether or not an appeal is a waste of time.

“How strong is the documentation on the case that was denied?” he asked. “If the documentation is really weak, you’re likely not going to win the appeal regardless, so you might as well rebill right now.”

Plus, the benefit of strong documentation from the get-go is that it can minimize the chances of a denied claim. Wuebker would prefer that facilities focus on the front end instead of the rebill after the fact.

To prevent a denied claim, there should be a first level of review with a nurse, then a second level of review with a physician, he recommended, in order to ensure the documentation is solid.

“I almost think about it in terms of immunizations,” he said. “If you can do whatever is possible to prevent that denial from ever happening, that’s the much better process.”

There are also 2 myths that Wuebker took the time to dispel, the first being that there are no audits going on right now because of the ICD-10 delay.

“And that absolutely couldn’t be further from the truth,” he said. “Yes, the total volume is down. But how you perform on audits right now is going to determine the amount of scrutiny in the coming 6, 12, 18 months. So this is the time to be sure that you really get it right.”

The second myth is that attending physicians can handle it all. However, Wuebker pointed out, physicians can barely keep track of things on the physician billing side, let alone the hospital billing side.

“For anyone who has dealt with the average physician in a hospital, they just don’t care about billing,” he said. “They’re interested in taking care of patients.”

Overall, the claims process can be slow-going when rebilling a claim, Wuebker said, and he recommended that practices and hospitals be diligent once everything is submitted.

“Unfortunately, the contractors have been a little bit behind on processing those claims,” Wuebker said “So be patient, but be persistent.”