Fighting Denied Emergency Room Claims

Fighting denied emergency room claims is one of the biggest headaches in medical billing. We've all been there - dealing with that sinking feeling when yet another ER claim comes back "denied as not medically necessary." But don't give up! With the right strategies, you can overturn many of those wrongly denied claims.

Understand the Prudent Layperson Standard

This is rule #1 for ER claim appeals. Federal law requires that insurance companies judge ER visits based on the way an average person would perceive their symptoms, not on the ultimate diagnosis. As long as the patient had symptoms that a "prudent layperson" could reasonably view as an emergency, the visit should be covered - even if it turned out to be a false alarm.

Too often, payers improperly deny claims using the logic: "Well, it was just a stomachache, not a heart attack." That's the wrong standard. The prudent layperson rule says they have to look through the lens of a non-medical person in the moment. Severe abdominal pain, uncontrolled bleeding, difficulty breathing - those all qualify, regardless of the final diagnosis.

A personal example: I had a patient come in with jaw pain, nausea, and dizziness, fearing a heart attack. The workup was clear, but the insurer still denied the claim as "not an emergency." Hello?! Those are textbook heart attack symptoms! We fought that denial using the prudent layperson argument and won.

Collect Detailed Documentation

The more ammo you give them, the harder it is for payers to deny. From the first second the patient walks in, carefully document:

• Chief complaint in their own words


• Time course of symptoms


• Severity level (1-10 rating or descriptors like "agonizing")


• Additional symptoms like dizziness, sweating, nausea


• Photos of visible symptoms like injuries or rashes


• Witness statements from family about symptoms

Having this level of detail makes your case airtight. Adjusters can't argue with contemporaneous records, time-stamped photos, or written statements describing what the prudent layperson saw.

One tip: Make sure coders select ER diagnosis codes that exactly match the presenting symptoms and complaints, not just the end diagnosis. That strengthens the medical necessity argument.

Hit Them With Policy Provisions

Most health plans have provisions written right into the documentation spelling out when ER visits are covered. For example, common language is: "Emergency services will be covered if you had symptoms that a prudent layperson would consider an emergency."

When you appeal, directly cite and quote those sections! It's much harder for them to deny when you're just asking them to follow their own written rules. Adjusters can't as easily brush you off.

I've had many instances where pulling out that policy language made the difference. One particularly stubborn insurer routinely denied almost all our ER cases but immediately overturned their decision when I cited word-for-word from their own Evidence of Coverage.

I know, reading through those giant policy tomes is a slog. But taking the time to find and flag the relevant ER coverage provisions pays off big.

Have a Defined Appeal Escalation Path

Don't get stuck in review limbo. Map out a firm escalation strategy to take denials up the chain if they're not properly overturned.

An example process:

• If a claim is denied, send a written appeal letter with supporting documentation within 60 days.

• If appeal is denied again, promptly request your first-level review with the insurer's appeal department within their stated timeframe.

• If you lose that appeal, exercise your right to an independent third-party external review within 60 days.

• If the external reviewer also sides against you, you may still have the option for a final appeal in your state's judicial court system.

Don't get discouraged and give up after one denial. Persistently working denials up the ladder makes insurers take you seriously. Tools like AI-powered appeal letter generators based on past successful appeals can streamline the paperwork.

Be polite but stern. I can't count how many ER claims I've won simply through sheer tenacity, refusing to back down and consistently escalating with a well-written appeal at each stage of the process.

Conclusion

Overturning emergency room claim denials is an uphill battle, but definitely a winnable one with the right approach. Arm yourself with prudent layperson knowledge, meticulous documentation, policy language citations, and a clearly mapped escalation plan. Don't get frustrated - dig in and fight!

The revenue impact of recovering these high-dollar ER claims is huge. Even a 20% overturn rate on a $10 million book of ER charges means $2 million back in your pocket. It's more than worth taking a feisty approach and refusing to take "denial" for an answer.

So study up on those prudent layperson rules, collect your evidence carefully, and get scrappy about taking denied ER claims to the next level of appeal. Your cash flow will thank you!