A Winning Appeal When insurers deny a claim, filing an appeal can result in payment for the clinician and improved coverage policies in the future. Bottom Line
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Bottom Line  |   June 01, 2017
A Winning Appeal
Author Notes
  • Janet McCarty, MEd, CCC-SLP, is director of ASHA private health plan reimbursement. jmccarty@asha.org
    Janet McCarty, MEd, CCC-SLP, is director of ASHA private health plan reimbursement. jmccarty@asha.org×
  • Sarah Warren, MA, is director of ASHA health care regulatory advocacy. swarren@asha.org
    Sarah Warren, MA, is director of ASHA health care regulatory advocacy. swarren@asha.org×
Article Information
Practice Management / Bottom Line
Bottom Line   |   June 01, 2017
A Winning Appeal
The ASHA Leader, June 2017, Vol. 22, 34-37. doi:10.1044/leader.BML.22062017.34
The ASHA Leader, June 2017, Vol. 22, 34-37. doi:10.1044/leader.BML.22062017.34
A client’s health plan has denied your claim for audiology or speech-language treatment. Now what?
Appealing denied claims, while admittedly a hassle, can yield short-term and long-term results with all payers, including Medicare, private health plans, TriCare and Medicaid.
In the short term, you receive payment for your services. In the long term, each appeal challenges a health plan’s coverage policy decision, and provides a platform for making the argument for better coverage of the targeted treatment. Over time, successful appeals can result in broader coverage for speech-language treatment. If an appeal is unsuccessful, the provider receives no reimbursement or must pay back any funds received.
Consider what happens if clinicians don’t appeal: By accepting poor coverage policies or denials, we allow payers to dictate audiologists’ and speech-language pathologists’ scope of practice.
Here’s a look at the appeals processes for major payers and how appeals serve as an advocacy tool, bolstering payment for audiology and speech-language pathology services.
Medicare
The success rate for Medicare appeals is trending down. In 2008, 50 percent of Part A appeals and 65 percent of Part B appeals were at least partially successful; in 2012, those figures were 24 percent and 51 percent, respectively, according to a report from the Office of the Inspector General. But you can still succeed by filing an appeal.
However, few denials are appealed—only 2.4 percent of denied Part A claims and 3 percent of Part B claim denials were appealed in 2015.
Medicare coverage rules are outlined in an annually updated code of federal regulations and in a variety of provider manuals. These policies are further refined by Medicare Administrative Contractors (MACs)—the independent entities that administer the program on the government’s behalf. Each MAC issues its own local coverage determination (LCD), a document that further refines coverage guidelines.
An LCD might include information, for example, about which procedure codes (from the American Medical Association’s Current Procedural Terminology, CPT) and diagnosis codes (from the International Classification of Diseases, 10th edition, ICD-10) it covers, or about policies associated with group treatment. If a claim includes ICD-10 codes that are not included in the LCD, or if the claim is missing certain CPT modifiers, the MAC will reject the claim.
If an LCD includes poor coverage policies or fails to include diagnostic codes relevant to the clinical practice of audiologists and SLPs, these need to be challenged proactively through the formal reconsideration process to avoid claims-processing headaches and unnecessary claims denials. For example, the LCD might restrict the size of a therapy group to four patients, and may allow only 25 percent of a patient’s treatment to be in a group. Certain clinical conditions, however, may lend themselves to more group therapy, so a blanket policy may not be appropriate. Providers can ask MACs to reconsider an LCD, and MACs must provide information on their reconsideration process on their websites.
ASHA often receives calls from members working in medical facilities, such as hospitals or skilled nursing facilities (SNFs), who discover a pattern of denials for their services over several months—but not until after the deadline to file an appeal. Clinicians often receive little information from their administration or billing departments as to why the claim was denied. Anecdotally, facility-based members report receiving very general explanations for denials, such as “Medicare doesn’t cover that anymore.”
Once you have decided to appeal, it’s important to understand the process. Medicare has a five-stage appeals process, each with associated timelines. If a claim is denied because the services are not “reasonable and necessary” and you disagree or have additional documentation that can establish otherwise, then an appeal is appropriate.
Sometimes appeals begin at the facility level. For example, in 2016 a SNF-based SLP was told by facility administrators that Medicare does not cover SLP-provided cognitive treatment. The SLP asked for help from ASHA, which discovered that the administrators were basing their directive on outdated information—a 2009 LCD that had been reversed long before 2016. The SLP used the correct information to provide cognitive treatment to the SNF patients.
The Medicare Learning Network offers a guide on the appeals process for Medicare Parts A and B.
Private health plans
According to a report by the Government Accountability Office, 40 percent of private health plan appeals result in reversals. Additionally, appealing private health plan denials can encourage plans to expand, update or add new coverage.
Commercial payers deny speech-language and hearing claims for a number of reasons, such as the services are not medically necessary, there is insufficient evidence of their efficacy, or they are considered experimental. You need two items to consider an appeal: the patient’s coverage information for the treatment you provide and an explanation of benefits (EOB) or denial letter from the health plan. If coverage language supports—or could be interpreted to support—payment, write an appeal letter describing the disorder and its medical nature, and reference the coverage policy paragraph that shows how your treatment fits coverage criteria.
Definitions of medical necessity vary, but usually focus on services being reasonable and necessary for the treatment of illness, injury, disease, disability or developmental condition, and many speech-language and hearing deficits meet this definition. Insufficient evidence may mean that studies of the treatment have not been conducted, are not of sufficient quality to draw conclusions about outcomes (often some evidence is available to dispute that stand), or have not addressed specific areas of the treatment.
Garner support for your appeal by sending a copy to your state insurance commission.
ASHA offers several letters that members can use to appeal denials for childhood apraxia of speech, muscle tension dysphonia, stuttering, cognitive rehabilitation and payment for an electrolarynx. Staff have also helped clinicians write appeal letters for auditory rehabilitation, pediatric dysphagia and many other disorders.
Health plans conduct an internal review of the denial. If all levels of appeal are exhausted, and you still believe your treatment meets coverage definitions, consider taking the case to the external claim review level. New standards for external review processes in the Affordable Care Act ensure a patient’s right to appeal plan decisions. The rules allow for an independent review organization to uphold or overturn the plan’s decision and require plans and issuers to comply with state or federal external review processes. These consumer protections, however, like all regulations under the Affordable Care Act, could change with the new administration’s focus on repeal and replacement of the law. The Kaiser Family Foundation has information on state external appeals.
Medicaid
You can also appeal denials by Medicaid. For example, often Medicaid programs limit the number of codes that can be used per discipline. For example, SLPs may be authorized to use only procedure code 92507 (speech-language treatment), but may use it to describe all procedures, including swallowing. This policy may then cause problems for clinicians who provide swallowing treatment (92526). Medicaid agencies should provide such coding clarifications. If using 92526 for swallowing treatment results in a denial, clinicians should appeal this denial.
Medicaid may also deny claims for services provided by multiple disciplines on the same day—if the claims are not coded correctly. For example, an SLP who owns a clinic that includes speech-language and occupational therapy services receives a denial for speech-language treatment (CPT 92507) and occupational therapist-provided therapeutic activities (CPT 97530) on the same day. Medicaid may claim that 97530 is included in 92507.
The clinician can appeal the decision, making sure to differentiate the services provided by different disciplines by using appropriate provider modifiers for the two codes—GN for the SLP and GO for the occupational therapist. Another modifier (–59) could be added to 97530 to indicate that a distinct service was provided.
Providers should note that claims reviewers may not be clinicians, and therefore need to distinguish between services.
Tricare
Audiologists and SLPs can also appeal denials from Tricare (a health care program for eligible members and retirees of the U.S. Armed Forces) as they would for private insurers, as private health insurance companies manage Tricare’s administrative needs: Review the explanation of benefits or letter of denial, as well as the contractor-specific provider manual and Tricare’s reimbursement and policy manuals.
Each Tricare contractor has a specific appeals process. An additional tactic, unique to Tricare, is to send the appeal letter to the patient’s representatives in the U.S. Congress, many of whom champion services for military personnel, veterans and their families.
Resources
ASHA can help with appeals by reviewing denial documentation, analyzing coverage policies, offering guidance, and facilitating or preparing appeal letters. Contact the appropriate staff member for help:
7 Tips to Avoid Insurance Coverage Denials

“Know the Medicare Correct Coding Initiative (CCI) edits that determine what procedures can—and cannot—be billed together for SLPs and for audiologists.” Private payers may also follow these rules.

  • Familiarize yourself with relevant diagnosis (ICD-10) and procedure (CPT) codes and rules.

  • Stay on top of coding and policy changes.

  • Know the coverage policies for the payers in your community.

  • Determine if the insurer requires prior authorization for treatment.

  • Get to know your administrative and billing department colleagues so you can be more involved in appeals for your services.

  • Know relevant code modifiers, such as the KX modifier (used when a patient exceeds the Medicare therapy cap).

  • Establish policies and procedures for how claim denials and appeals will be handled in your setting.

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FROM THIS ISSUE
June 2017
Volume 22, Issue 6