Don’t Underestimate the Importance of Directing Appeals to the Correct Person
Insurance companies receive, review and uphold thousands of medical appeals each year. Should you be detered if you receive a letter stating your appeal letter was reviewed and the decision to deny payment was upheld?
Absolutely not.
If the argument you set forth in the appeal was not fully addressed during the appeals process, you should get the company’s president or legal counsel involved in the review. Many times, an insurance company’s upper management will reconsider payment on a claim when the medical provider is not satisified with the decision of the appeal reviewer.
However, you have to make your request for intervention clear and convincing. Letters to an insurance company president or legal counsel should be specific as to where the appeal reviewer failed in the review of your claim. Some of the potential complaints providers may have concerning the review process may be:
- The appeal reviewer did not fully review a certain portion of the medical records. State which portions you wish to be reviewed and addressed.
- The appeal reviewer was not trained in your medical specialty.
- The appeal reviewer did not gather sufficient proof to justify the denial. Even though the carrier may have an official position on the treatment course, the reviewer must still assess the appropriateness of this particular treatment for this particular patient.
- Case or statutory law was cited in your initial appeal letter. However, the reviewer failed to cite any case or statutory law in the carrier’s favor or offer a different interpretation of the law which you quoted. If the reviewer essentially ignored law your letter cited, an additional review is justified.
When you follow up on the status of these letters, your call will likely be screened by the management party’s assistant. Clearly state that the information you want to discuss is highly technical and you need to speak directly with Mr. President or Mr. Legal Counsel. If the company president fails to respond within a reasonable time, direct the letter to the legal counsel and vice versa.
If you are seeking reconsideration on a number of claims dealing with the same issue, seek a face-to-face meeting with top management officials. Ask that the meeting take place in your office. You can then assemble the many parties affected by the denials including professional staff, billers and even patients.
Follow up any phone and face-to-face conversations with a letter detailing what issues were resolved and your understanding of how future similar claims will be processed. If there are still unresolved details, you will need to restate your position on these issues and indicate that you would like a written response regarding the unresolved issues.
Remember, tenacity may be your biggest asset when appealing claim denials. Do not give up until you are satisfied with the answer you receive.
Leave A Response