After a 3rd level appeal


I was wondering if anyone had experience with denials from commercial payers that goes beyond the 3rd level of appeals.  We are getting response letters that state "completion of a level 3 dispute exhausts internal administrative rights."  Curious what other hospital systems are doing with this.  Anyone willing to share their current process?

Thank you!


  • Hi Cdrum,
    There are limited options after a level 3 commercial denial, but what I suggest is to rate your denials to see the ones that were incorrectly denied and pursue a legal escalation process to get the maximal ROI. Hope this helps. 
  • I have been currently investigating this topic as we have received several egregious denials. What I have found is this:

    -Payors generally have an appeals "policy" that someone in revenue cycle can direct you to

    -Our payment manager suggested to call the insurance company and request to speak with a manager and discuss situation

    -As part of the contracting services, there is usually a customer service representative that a payment variance manager can contact and discuss the case with (after all appeal processes have been completed)

    We have gotten some really inappropriate denials particularly from a company called Cotiviti and so far every appeal has been upheld, we have not exhausted out efforts. Some of these accounts are large dollar accounts and I will recommend legal action if we cannot come to a resolution. Many companies do include in their contract thought that prohibit legal action but allow arbitration from an independent source.
  • Given Cotiviti is not the payer, but a contractor for the payer, you will have multiple levels of appeal for DRG downgrade denials and following your denials, you have the option to have a peer to peer like call. You can take it up to 5 levels and the peer to peer as a level 6. 
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