Pediatric care often involves aggressive medicine. Pediatric care givers are well known for their tenacity in providing their young patients with the future they deserve. Diagnostic medicine, too, is often made more complex with pediatric patients. The demands of pediatric care often are at odds with the constraints of black and white coverage terms.
For these reasons, pediatric claim appeals must be aggressive as well.
- Pediatric claim appeals are often necessity to address the medical necessity of care in question. To effectively appeals such denials is important to address the following in each appeal:Demand pediatric peer review of the denial. It is important to seek peer review of any denial which directly affects the quality of care provided by your organization. Use wording such as the following or customize the wording to cite potentially applicable legal protections related to the denial:
It is our position that your organization’s clinical review criteria may allow benefits for the pediatric care recommended by the treating pediatrician. Attached are the medical records which demonstrate the complexity of care and need for the recommended care. As you know, many state and federal claim processing regulations require peer review of a health benefit denial. Therefore, we request that a board certified pediatrician review the denial of benefits. If the medical records do not sufficiently demonstrate the medical necessity of the care provided, please have the pediatrician responsible for the peer review to contact Dr. (treating pediatrician) immediately. This will allow Dr. (pediatrician) to more completely describe the necessity of this treatment.
- Demand the release of the clinical review criteria used in the decision-making. More than 1500 clinical practice guidelines have been developed in the U.S. according to a 1998 article in Pediatrics (PEDIATRICS Vol. 101 No. 5 May 1998, pp. 825-830). There have been vast changes in how they are written in regards to precision and population inclusion. To fully determine if the clinical guideline is appropriate, pediatric care givers should review the clinical guidelines with particular attention to the publisher, the date of development and quality of the guideline development. If the guideline does not adequately address the patient’s medical challenges, the appeal should highlight inadequacies in the guideline application and differentiate the patient’s medical condition from the patient population studies in the clinical guideline development.
Leave A Response