Patient Stories: Do They Belong In Appeals?

Patient stories are the pulse in healthcare communication.

“Open all meetings with a patient story—good or bad—and make sure the importance of patient centricity is the message communicated at all leadership meetings,” states the Press Ganey whitepaper “A Strategic Blueprint for Transformation Change,” released this month and available at

Do appeal letters fall within to scope of communications which could be improved with stories? It is definitely possible.

Patient appeal letters are often filled with very specific details regarding how the patient’s quality of life has been impacted. Yet, now that many appeal letters are developed by healthcare organizations, payers may have far less insight into this aspect of appeal review.

In the coming weeks, review your organization’s appeal letters to see if any would benefit from more patient narrative. A way to develop this narrative is to give the payer a better understanding of the progression of the patient’s condition and the specific impacts to the patient’s normal activities. For example, it doesn’t hurt to point out that the avid golfer is sidelined by his/her condition. Medical records often contain this type of information but it may require going back to the start of the patient’s healthcare challenges in order to locate specific details.

If your organization utilizes form letters to initiate appeals, you may want to consider adding prompts within the form for the user to populate with patient-specific information. Some of our appeal letter forms utilize the following prompt:

This attached medical record contains a detailed account of the patient’s condition related treatment decisions. Unfortunately, despite numerous and persistent efforts, using various modalities, my patient’s condition deteriorated significantly and more aggressive intervention was mandated. Although consideration of the full medical record is essential to understanding the medical necessity of this treatment, the following details specifically support the medical necessity of this treatment:

  • Relevant History and Physical, SOAP, Clinical Pathway or Treatment Plan Information which discusses patient’s initial complaint and progression of condition
  • Previous medication/treatment efforts (include side effects if applicable and effectiveness or lack thereof).
  • Current treatment plan and medications/treatment efforts (include side effects if applicable and effectiveness or lack thereof).
  • Related treatment (indicate frequency, duration, and dates of recent hospitalizations related to condition).
  • Risk factors – Life or limb threatening nature of patient’s condition.
    Unresolved factors – pending diagnostic information or treatment goals not achieved

Further, payer may lack a clear picture of what your organization provides in the way of patient education and decision-making support. Look for ways to fill in this dialogue and demonstrate the shared decision making efforts your clinicians go through daily. If your organization conducts prior authorization appeals, details regarding decision-making and conditions under which the decisions are made can be compelling to reviewers who are looking for reasons to stray from their internal guideline and approve care which does not neatly fit in the guideline descriptors.

If you contrast patient appeals letters with those drafted by healthcare organizations, you will quickly see patients nearly always provide a personalized account of their healthcare challenges. Appeal specialists may, depending on their backgrounds, be inclined to focus on technical information in the appeal and forgo more complex quality-of-life issues.

However, consider that there efforts may allow you to better engage both patient and payer in good dialogue. Putting the patient’s own words into the appeals demonstrates a greater level of respect for their personal healthcare experiences. If you forward a copy of the appeal to patients, this extra effort may motivate them to take up other avenues of dispute resolution such as external review and even litigation, in order to achieve a fair review from the payer.

In closing, improving appeals in this way also makes your appeal process more “patient centered.” As explained by the Press Ganey article cited above:

“The term “patient-centered care” has become so familiar that its true meaning as it applies to the over-all care experience can get lost. Often, patient-centered care becomes a “lapel-pin campaign,” without significant depth in the organization to drive meaningful cultural alignment. The only way to fully deliver on the promise of patient-centered care is to define, communicate and integrate it in such a way that it is mirrored in every action, interaction and reaction across the organization. When such a culture prevails, all of the interdependent performance measures reflect it.”

Many patient finance experts are trying to bring a “patient-centered care” approach to business office functions. Achieving this goal will requires payers to improve their review performance as well. Many of the “interdependent performance measures” can only move in the right direction if payers are cooperative.

It may be necessary to ramp up patient advocacy efforts so that payers know they will expect to hear from your organization regarding any impact to treatment – from access to payment.

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