Urologists don’t recommend patients for open heart surgery. So should a urologists hired by an insurance company be allowed to make utilization review or appeal decisions related to cardiology treatment for an insurance company?
Now that insurance companies have substantial input in regards to the course of treatment, it is imperative that reviews, particularly reviews resulting in denials, be made by qualified professionals. Most importantly, a denial signed by an MD does not necessarily assure treating practitioners or patients that a quality review has been provided.
Unfortunately, if the medical credentials of the reviewer are not provided, it is often up to the treatment provider to demand information regarding the qualifications of medical reviewers rendering denials.
There are many consumer protections in place which require denial decisions in either the utilization review and appeal process to be made by a clinical peer. A clinical peer is often defined as a board-certified medical profession who practices medicine in the same profession and similar specialty as typically manage the medical condition under review.
One way to ensure that reviews are conducted by qualified personnel is to negotiate managed care contract terms which require any adverse determination to be made by a clinical peer in the same profession and similar specialty as that which typically manages the medical condition under review.
However, even if you do not have such protective wording or the treatment is out of network, be sure and make a formal request for the names and credentials of any reviewer who renders an unfavorable decision. Also, any medical necessity appeal should include a request for the insurance carrier to provide the name and credentials of the medical reviewer if that information was not provided in the initial denial letter.
If the insurance carrier refuses, determine if the coverage falls under any state or federal disclosure laws. If the claim falls under the ERISA Federal Claim Processing Guidelines, insurers are required to disclose this information as substantiation that the adverse determination was made by qualified personnel.
We have added a letter to the Topic “Medical Necessity,” Subtopic “ERISA Regulations,” which cites information from ERISA which indicates that insurers must provide an expert review and disclose details regarding the credentials of the reviewer. Look for the letter titled “ERISA Request for Expert Review.”
If the denial falls under state insurance mandates, review the Topic “Benefit Reductions,” Subtopic “State Mandates” and see if there is a letter citing your state’s disclosure law. Citing state disclosure laws often will assist medical providers in obtaining the name and credentials of medical reviewers.
Once this information is obtained, your office can assess the review for compliance with quality utilization review standards and take issue with any decision made by a professional unfamiliar with the treatment under review.
Leave A Response