Payment Appeals: Saying "What is Taking So Long" in Optimal Wording
some initial reports on ICD-10 claim processing have been favorable, many
providers are experiencing payment delays and other revenue cycle challenges
related to the coding transition.
Both CMS and RelayHealth issued claims processing reports reflecting
little change in denial rate metrics. According to the CMS report, denials
for October, 2015 were about ten percent of submitted claims. . . .
reading this article.
with prompt payment escalation and remittance transparency under ICD-10, we
have developed the following document available in the AppealLettersOnline.com
ICD-10 Prompt Payment and ERA
Clarification Guidance (new content!)
We also have state-specific letters citing state prompt payment
regulations for each state. Visit the AppealLettersOnline.com
Appeal Letter Repository to review these state-specific appeal
letters. If your state has issued any prompt-payment guidance related
to ICD-10, please let us know by emailing
We have also developed a number of follow-up letters for use during the
ICD-10 transition. These letters would not necessarily be considered "appeal
letters" since they primarily address a payers' lack of prompt processing
and/or lack of ERA transparency. Appeals are only initiated when a
clearly-worded denial has been received. Therefore, when using an inquiry
letter to follow-up on unprocessed/unclear remittances, the appeal process
restrictions on number of appeals should not be triggered.
Access the appeal
letters at AppealLettersOnline.com
Spotlight: Medicaid - Performance Concerns Amidst Medicaid Population
is being closely monitored by CMS for ICD-10 compliance.
According to CMS's State Medicaid ICD-10 Readiness page, more than 70% of
Medicaid is provided through managed care. CMS has ensured that each state is
working with their Medicaid managed care organizations (MCOs) to ensure that
they are ready to receive and process ICD-10 claims. States’ general
practices have included requiring the MCOs to attest to their readiness
and/or share their own test results.
Medicaid organization are of particular concern under the transition due
to historical performance on claims process. AthenaHealth's Payerview Report
has outlined the following performance challenges specific to Medicaid
historical claims data analysis:
- Slowest to pay out. Compared with other payers, Medicaid is
consistently the slowest in days in accounts receivable (DAR) between charges
submitted and payment received.
- Highest denial rates, least transparent. When claims get denied,
it’s important for payers to return them with Electronic Remittance
Advice (ERA), including clear next steps and denial explanation.
Unfortunately, Medicaid has the highest denial rate - and also the lowest ERA
organization with a high Medicaid claim volume, be sure to track any updates
issued through CMS specific to Medicaid organization. The website is https://www.cms.gov/Medicare/Coding/ICD10/State-Medicaid-ICD-10-Readiness.html
and has state-by-state links to Medicaid ICD-10 Readiness updates.
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