Addressing claims payment issues can be complicated, but ensuring proper processing and payment of health care claims is vital to the financial health of a practice. The AMA offers resources to help physicians secure correct claims payment from health plans, navigate the overpayment recovery process and appeal incorrect payments.

Overpayment recovery toolkit

Attempting to determine the validity of alleged overpayments can divert significant time from direct patient care, resulting in lost practice revenue. Overpayment demands may be made in very general terms and can be intimidating. However, it is critical for practices to effectively and efficiently address overpayment recovery requests.

PDF 1: Overpayment recovery toolkit

To help physicians understand health insurer overpayment recovery requests, the AMA created the Overpayment Recovery Toolkit, which contains the following resources:

Designed to help physicians understand the basics of the overpayment recovery request process, this resource details the reasons that practices may receive overpayment recovery requests, the content of those requests and important information on what to look for in these notifications.

PDF 2: Recognizing and interpreting overpayment recovery requests 

This resource provides guidance to practices on how to investigate and take action when receiving an overpayment recovery request.

PDF 3: Addressing and resolving overpayment recovery requests 

Additionally, the AMA offers a template for practices to utilize.

PDF 4: Sample claim overpayment appeal letter (DOC) 

To help physicians save time and money, this resource explains how practices can automate the overpayment recovery process through use of standard electronic transactions mandated by the Health Insurance Portability and Accountability Act (HIPAA).

PDF 5: Automating the overpayment recovery process 

Additional information on how to effectively address overpayment recovery requests:

Webinar 1: Get overpayments off your back with practice automation 

This resource offers information on the responsibilities of health plans and the rights of physicians provided by many states laws and regulations. It is intended to ensure that physicians understand their rights in the overpayment recovery request process.

PDF 6: Knowing your overpayment recovery rights 

Appealing claims payment issues

Physicians generally collect the majority of their revenue from health insurers. To maximize revenue and maintain financial viability, practices need to ensure that health insurers are properly adjudicating their claims and should be prepared to address/appeal any improper health insurer payment adjustments. To help physicians understand and enact efficient appeals processes, the AMA has created the following informational resource and sample appeal letters:

PDF 7: Identifying and appealing health insurance claim payment issues

Sample appeals letters

AMA members can download these sample letters and customize them in their practices.

Authorization and eligibility

PDF 8: Letter confirming eligibility

PDF 9: Prior authorization not disclosed

PDF 10: Referral absent letter

Contractual obligation

PDF 11: Claims underpayment letter

PDF 12: Letter to health insurer regarding late payment of claims in violation of practice's contract

PDF 13: PPO discount taken when a contract does not exist

Medical necessity

PDF 14: Medical necessity denial letter

Payer-applied edits

PDF 15: Lack of recognition of CPT Modifier 25 letter

PDF 16: Lack of recognition of CPT Modifier 59 letter

PDF 17: Inappropriate E/M downcoding letter

PDF 18: Insurers not accepting new CPT code sets appeal letter

Prompt payment

PDF 19: Letter to health insurer regarding late payment

PDF 20: Letter to patient's employer or health plan sponsor regarding late payment

PDF 21: Letter to health insurer regarding late payment of claims in violation of practice's contract

PDF 22: Letter to insurance commissioner regarding late payment of claims in violation of prompt payment laws

General

AMA members can also access the National Managed Care Contract Database, where they can look up state laws and regulations to copy and paste into their appeal letters.

LINK 1: National Managed Care Contract Database

LinkedIn group

The AMA Administrative Simplification LinkedIn Group is designed to provide updates and encourage dialogue on administrative issues affecting physician practices, including automation using electronic standards and operating rules, prior authorization standardization and reform, and regulatory developments. Physicians, practice staff and other interested stakeholders are encouraged to join.

LINK 2: AMA administrative simplification LinkedIn group

Addressing claims payment issues can be complicated, but ensuring proper processing and payment of health care claims is vital to the financial health of a practice. The AMA offers resources to help physicians secure correct claims payment from health plans, navigate the overpayment recovery process and appeal incorrect payments.

Overpayment recovery toolkit

Attempting to determine the validity of alleged overpayments can divert significant time from direct patient care, resulting in lost practice revenue. Overpayment demands may be made in very general terms and can be intimidating. However, it is critical for practices to effectively and efficiently address overpayment recovery requests.

PDF 1: Overpayment recovery toolkit

To help physicians understand health insurer overpayment recovery requests, the AMA created the Overpayment Recovery Toolkit, which contains the following resources:

Designed to help physicians understand the basics of the overpayment recovery request process, this resource details the reasons that practices may receive overpayment recovery requests, the content of those requests and important information on what to look for in these notifications.

PDF 2: Recognizing and interpreting overpayment recovery requests 

This resource provides guidance to practices on how to investigate and take action when receiving an overpayment recovery request.

PDF 3: Addressing and resolving overpayment recovery requests 

Additionally, the AMA offers a template for practices to utilize.

PDF 4: Sample claim overpayment appeal letter (DOC) 

To help physicians save time and money, this resource explains how practices can automate the overpayment recovery process through use of standard electronic transactions mandated by the Health Insurance Portability and Accountability Act (HIPAA).

PDF 5: Automating the overpayment recovery process 

Additional information on how to effectively address overpayment recovery requests:

Webinar 1: Get overpayments off your back with practice automation 

This resource offers information on the responsibilities of health plans and the rights of physicians provided by many states laws and regulations. It is intended to ensure that physicians understand their rights in the overpayment recovery request process.

PDF 6: Knowing your overpayment recovery rights 

Appealing claims payment issues

Physicians generally collect the majority of their revenue from health insurers. To maximize revenue and maintain financial viability, practices need to ensure that health insurers are properly adjudicating their claims and should be prepared to address/appeal any improper health insurer payment adjustments. To help physicians understand and enact efficient appeals processes, the AMA has created the following informational resource and sample appeal letters:

PDF 7: Identifying and appealing health insurance claim payment issues

Sample appeals letters

AMA members can download these sample letters and customize them in their practices.

Authorization and eligibility

PDF 8: Letter confirming eligibility

PDF 9: Prior authorization not disclosed

PDF 10: Referral absent letter

Contractual obligation

PDF 11: Claims underpayment letter

PDF 12: Letter to health insurer regarding late payment of claims in violation of practice's contract

PDF 13: PPO discount taken when a contract does not exist

Medical necessity

PDF 14: Medical necessity denial letter

Payer-applied edits

PDF 15: Lack of recognition of CPT Modifier 25 letter

PDF 16: Lack of recognition of CPT Modifier 59 letter

PDF 17: Inappropriate E/M downcoding letter

PDF 18: Insurers not accepting new CPT code sets appeal letter

Prompt payment

PDF 19: Letter to health insurer regarding late payment

PDF 20: Letter to patient's employer or health plan sponsor regarding late payment

PDF 21: Letter to health insurer regarding late payment of claims in violation of practice's contract

PDF 22: Letter to insurance commissioner regarding late payment of claims in violation of prompt payment laws

General

AMA members can also access the National Managed Care Contract Database, where they can look up state laws and regulations to copy and paste into their appeal letters.

LINK 1: National Managed Care Contract Database

LinkedIn group

The AMA Administrative Simplification LinkedIn Group is designed to provide updates and encourage dialogue on administrative issues affecting physician practices, including automation using electronic standards and operating rules, prior authorization standardization and reform, and regulatory developments. Physicians, practice staff and other interested stakeholders are encouraged to join.

LINK 2: AMA administrative simplification LinkedIn group

Webinar 1

Get overpayments off your back with practice automation

Additional information on how to effectively address overpayment recovery requests.

Why Join the AMA?

An AMA membership means you’ve got access to world-class clinical research, education and insights. Access peer-reviewed medical research findings and editorial opinions from JAMA®, the Journal of the American Medical Association, JAMA Network Open™ and the 11 specialty journals, with CME at no cost.

Join Now

Why Join the AMA?

An AMA membership means you’ve got access to world-class clinical research, education and insights. Access peer-reviewed medical research findings and editorial opinions from JAMA®, the Journal of the American Medical Association, JAMA Network Open™ and the 11 specialty journals, with CME at no cost.

Join Now