Appeals Go Electronic

The healthcare claims appeal situation is decidedly unappealing. Not only do denied or disputed claims and delayed payments add to healthcare providers' financial burden, but they've also prompted a mushrooming number of lawsuits against insurers and health plans, as well as investigations-and in some cases substantial fines-by government entities with oversight responsibility.

Six Billion Strong
Six billion healthcare claims are transmitted in a single year, including institutionalized claims and claims for professional services, and about 10%-or 600 million-are eligible for appeal, says Dr. William D. Kirsh, DO, MPH, former chief executive of a Florida-based health plan.

Migrating from Stone Tablet Carving to Fax to Electronic Submission
That's a staggering amount, particularly since up to now appeals have been handled manually. "Technology has been developed to advance the electronic submission of claims, but appeals are still manual," Kirsh says.

That's a situation he hopes is about to change. Frustration with the cumbersome process led Kirsh to develop an online tool called eAppealSolutions, which automates, and promises to ease, the medical insurance claims appeal process. The Web-based system includes electronic document management, tracking, and monitoring, as well as automatic appeals escalation, which can take a claim as high as the state level for review. Healthcare providers and outsourcing companies can utilize it to appeal denied or partially paid claims. Consumers can also use it to appeal both service and payment denial.

Tested and Proven
Under development for roughly three years, eAppealSolutions was formally rolled out earlier this year. The lengthy development time was needed to build the complex rules engines so that, depending on the line of business, an electronic appeal would be put in the right form and sent to the right address, Kirsh explains. There are so many different rules governing appeals, he points out, with Medicare rules differing from commercial insurance or self-insure programs. The rules are also different-and stronger-for handling consumers' appeals.
James D. Turner, president, MediBillers Inc., headquartered in Philadelphia, is an early adapter. His firm has been using eAppealSolutions for about eight months, and he considers it a cost-effective and efficient tool. "I see it allowing us to handle more appeals with fewer staff because it can handle [a substantial number of claims] without running them through people," he says. In his firm's experience so far, 40% of the appeals handled electronically resulted in a denial being overturned. His staff is then free to concentrate on the remaining 60%.

Nothing significant to install
Rather than sell the software, Kirsh set up eAppealSolutions as an Application Service Provider, or ASP, with users charged by the transaction. There's no connection fee, Kirsh says, so the return on investment is greater. And according to Turner, the software needed is not complicated to install. "Our IT staff did it over the phone, with eAppeal support," he says.

Automate your appeals process and collapse your collection cycle
Automating appeals seems like the logical next step after electronic submission of claims. It not only allows staff to work more efficiently Kirsh points out, but by automatically following the rules for a particular type of claim, avoids mistakes introduced when appeals are handled manually.

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