The healthcare appeals process can be difficult to navigate. How can we ensure that patients easily understand the process and their healthcare coverage?

By Nan Sloan, Vice President of Compliance, Medecision

Our healthcare system has made itself so complex that there’s no way a person can easily navigate it. Patient advocacy and education have long been among the missing pieces of the puzzle. Rules handed down in January 2020 aim to change that.

In my previous blog post, I discussed improving compliance for Medicaid populations. The new rules require that all communications be understandable to members and patients. That includes notifications of the denial of services, as well as information about their right to appeal, their options and the process for appeals.  (Note: When I say “appeals” in this context, I am referring to a member’s or patient’s response to a denial of services, whether that amounts to no services, insufficient services, the wrong services or an inadequate time frame.)

Here are three key points to keep in mind:

  • When you send a denial letter to a member, you must be very clear in communicating why the claim was denied.
  • When a claim is denied, the provider must provide the resources to help the member navigate the appeals process.
  • Medicaid will reimburse the payer for the time spent providing those services if the appeal is lost.

Patient Advocacy and Education for the Appeals Process

The widespread need for patient advocacy and education truly hit home for me last summer after my mother-in-law’s claim was denied. The appeals process was too complex for her to understand, and we had to get an attorney involved. My husband is a doctor and I work in the compliance realm of healthcare, and we argued back and forth with the provider of her care before ultimately losing the appeal. While that wasn’t the end of the world for us, it impressed on me the plight of those who don’t have a caregiver or advocate to fight for them and who, in many cases, don’t understand what an appeal, a grievance or even a claim is.

In the past, the modus operandi has been to throw the denial over the wall to members or patients and say, “Good luck.” But now providers must provide the necessary support for them through the appeals process.

Social Determinants of Health

The best appeal, of course, is the one you never have to make because the claim is not denied in the first place. And information is everything.

As is so often the case in today’s healthcare industry, social determinants of health (SDOH) play an outsize role. Let’s say, for example, that a member is told, “We’re going to give you 10 physical therapy visits, but you have to complete them in two weeks.” If that member doesn’t have a car and is in a transportation desert, chances are he or she will not be able to finish those 10 visits in two weeks. So how do we help them do that?

As the appeals process and the tracking and sharing of information become more robust at leveraging SDOH, we’ll be able to identify potential issues upfront by looking at the patient’s socioeconomic status and other demographic data. The issue could be transportation, prescriptions or any number of factors. Software vendors are now being asked that their programs allow for the consideration of SDOH in member management to enable accurate decisions about the healthcare services that need to be provided—and to reduce the chance that what you request gets denied.

Documentation and Communication

Other important tips to keep in mind:

  • Document everything. In supporting a member’s or patient’s need for services, you have to look at that person as a whole, not just in pieces. Look at the environment they live in, their caregivers, their mental health, their job, all those factors, before making your decisions. “Resources” can mean a lot of things: transportation, caregivers, medication, money and more. We must get better at communicating what we mean.
  • Be timely. If you don’t have the appropriate information readily available for submission, it can be hard to make decisions within the 24 to 72 hours window requirement for services that your member may need as required under the regulatory changes.
  • Use professional content providers if needed. They can help produce letters and messaging at the right level for members and patients.

The Pressure Is On

Chances are, case managers will become increasingly involved in the appeals process to ensure that the right services go to the right patient or member at the right time for the right need, with the right resources available. Beyond that, the government is applying its own pressure.

Many states now require certification by the National Committee for Quality Assurance (NCQA) in Medicaid populations to do business with government contracts. That means you must track and report on how you’re managing the appeals and grievances process. Are you making sure that members and patients clearly understand their rights and responsibilities and the process for appeals and grievances? Third parties look at your documentation from a compliance perspective to ensure that you are fulfilling this requirement.

Understanding means asking questions. If you have 10,240 denials but only 120 appeals, that is sure to raise a red flag. You’ll be asked: Is there a breakdown in the education you provide to your members and patients, and where is it?

Sharing a better, more complete view of the patient with everyone who helps manage their care—payer to payer, payer to provider, payer to member—is the only way we’ll get to the level of communication that interoperability demands. And, with older Americans being one of the two primary targets of Medicaid (those with disabilities are the other), we also must consider that they often are not savvy computer users.

As we consider how to ensure that members and patients receive their information in a timely manner so they (or their representative) can understand it and, if necessary, file an appeal, the scope of the challenge might appear daunting. Indeed, it’s not an easy problem to solve, and we’re not miracle workers, but we must figure out how to solve it. There are a lot of smart people in healthcare, and with the right processes, software and other tools, we will figure it out.


Hear more from Nan Sloan as she discusses Improving Compliance for Medicaid Populations and Final Updates to the Stark Law that Will Ease the Transition to Value-Based Care.

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