Creating the Narrative

Posted on March 11, 2020
By Denise Wilson

The Narrative

Every appeal letter includes a narrative that tells the patient’s story. The narrative explains why the claim submitted for the services provided to the patient should have been paid as billed. The narrative is the most significant part of the appeal letter. The narrative offers the writer the opportunity to deliver a persuasive argument for appropriate payment by crafting a compelling, but truthful, story of the patient’s medical episode. The narrative can be made compelling in several ways. Referring to the patient by name helps put flesh on the patient and bring them to life for the reader. Citing abnormal exam and lab findings while ignoring the normals emphasizes the seriousness of the patient’s condition. Explaining the relevance of signs, symptoms, assessment, and test results connects the medical record documentation to the significance of the patient’s illness and risk of injury, harm, or death without appropriate medical care. Using a bold font judiciously helps direct the attention of the reader to the most critical information and events in the medical record.

In the case of level of care appeals, the narrative tells why the services provided were billed appropriately as inpatient services rather than outpatient services. The narrative directly refutes incorrect statements in the payer’s decision to deny inpatient payment; if the payer has provided a denial notice with an explanation of the denial reason. Sometimes the denial notice includes only a reason code such as Reason Code 50: Not Medically Necessary, without further detail on why the payer considers the services billed as not medically necessary.

Content

The narrative in a level of care appeal includes certain content such as: medical history, family history when appropriate, presenting signs and symptoms, physician office, prior treating hospital, or emergency department (ED) assessments, testing, test results, treatments and response to treatment, the decision to admit to an inpatient setting,

the relevant hospital course with emphasis on documentation in the record that supports the inpatient setting; and, a direct disproving of the payer’s incorrect statements regarding the reason for the denial or underpayment.

Flow

The narrative should flow logically and chronologically. However, for claims paid on a DRG, the narrative does not need to be a day by day review of the patient’s stay. A daily summary of the patient’s stay may be necessary for arguing denied per diem days.

Start the narrative by clearly stating the facts of the denial and the reason for the appeal. For example:

 “PayerABC denied inpatient payment for John Doe’s hospitalization at Memorial Hospital from December 8, 2019, through December 12, 2019. PayerABC claims that an inpatient setting was not reasonable or medically necessary to treat Mr. Doe and that care could have been provided in an outpatient setting. This letter represents a request for an appeal for inpatient payment with substantiation of the medical necessity that supports the need for services as provided and billed.”

It can be helpful to use the name of the level of appeal assigned by the payer. Payers may refer to the first level of appeal as re-determination or reconsideration. For clarity, the appeal writer should use the words re-determination or reconsideration in place of the word appeal.

Begin with a brief introduction of the patient, patient’s age, disabilities, living conditions, and family history, if pertinent. Refer to the patient by name. Use the terms lady or gentleman instead of beneficiary or patient to bring the patient to life for the reader.

Describe the patient’s presenting signs and symptoms, whether documented in the referring physician’s office notes, the transferring hospital’s records, or the ED. A best practice is to focus on the abnormal findings and ignore the normal findings. Presenting only the abnormal findings keeps the appeal argument focused on the reason for the inpatient admission while avoiding clutter that does not add to the argument.

Abnormal lab findings should be documented as the value, followed by the letter H, L, or C in parenthesis to indicate high, low, or critical value. Follow that with the normal lab value range in square brackets. Example, Potassium 6.0 (C) [3.5-5.5]. This format helps readers without a strong clinical background, such as administrative law judges, understand the gravity of the abnormalities. Omitting the value descriptors such as mg/dl helps eliminate clutter in the letter improving readability.

The ED physician’s presumed diagnosis can help support the reason for admission. Patients who leave the ED with a confirmed or strongly suspected diagnosis are generally more appropriate for an inpatient setting. Patients admitted to rule out, monitor, or further evaluate their condition are less likely to be seen by payers as appropriate for inpatient admission.

Persuasion

The narrative should be persuasive in influencing the payer to reverse the decision to deny or reduce payment for the inpatient stay. The narrative should provide critical analysis of the presenting and developing signs and symptoms observed in the patient. Include a discussion of the risks for an adverse event or worsening of symptomology in the absence of immediate and intense care provided in a hospital setting. Tell the payer why care in an outpatient setting would not be successful or appropriate for the patient’s condition, especially if outpatient treatment had already been attempted and failed. Don’t expect that the payer will perceive the seriousness of the patient’s illness or the risk of adverse events based on a list of signs, symptoms, tests, and exams. Explain to the payer the significance and severity of the abnormalities documented in the medical record.

Standards of Care

Every payer publishes a definition of the medical necessity or appropriateness of inpatient admission. Regardless of payer, the definitions always rely in part on what is considered the standard of care in the medical community. It is the job of the appeal writer to connect the dots between the patient’s presentation and the standard of care. Interpret the facts and information in the medical record in a way that drives the payer to a decision to pay the claim when appropriately billed. References to standards of care can be included in the narrative or listed in another part of the appeal letter. A compelling argument draws a direct line between the patient’s condition and the need for inpatient admission, critical care, intense medical services, risk of adverse events including morbidity or mortality, or greater than two midnights of hospital care as recommended and published by medical experts in the healthcare community. Use quotations from reputable published standards of care that support the need for hospital care. Cite the published literature using a recognized format such as APA and include the URL to the article.

Finishing Touches

When traditional Medicare is the payer, note the dates and times of the patient’s presentation to the hospital, the admission order, and the effectuation of the discharge. Since the Centers for Medicare and Medicaid Services defines an inpatient based on the number of midnights the patient requires hospital care, among other things, it’s important to include dates and times of the events related to the hospitalization.

Use a bold font or underlining to highlight the critical aspects of the patient’s story so that if the reader does nothing but skim the appeal letter, the information in bold should be enough to persuade the reader to overturn the denial. Use bold or underline sparingly. The reader will tend to ignore bold or underline when there is too much of it.

Finish the narrative with a summary of the facts regarding the admission. Provide rationale that supports the facts. Explain why the patient required care that could only be provided in an inpatient hospital setting. Be sure to reiterate the expectation of the outcome of the appeal, such as: “Memorial Hospital provided medically necessary services to John Doe with the expectation that those services would be reimbursed according to the documentation in all payer communications.  Memorial Hospital requests that you reconsider this claim and require payment to be made to Memorial Hospital for the services provided to John Doe as originally billed.”