Persistence Beyond Initial “No” Wins Appeals: Second in our “How I Won My Appeal” series

Medical billing professionals will often give the appeal process one shot. If the argument looks good, they will pursue the Level I appeal.

Level II appeals, however, are often not pursued even if the Level I appeal letter was not reviewed carefully and the insurer failed to provide a good explanation for the denial. Many offices simply view higher level appeals as wasted time.

However, often, the payer provides only a cursory review of Level I appeals with little disclosure regarding how the decision was arrived at. For this reason, we recommend that all unfair denials be pushed through higher levels of appeal where more attention is given to quality appeal review. Some providers believe that if the appeal review at lower levels did not really provide a quality process, there is little hope for success at higher levels.

However, often a poor lower level review can be very beneficial. Your higher level appeal can focus on the shortcomings of previous reviews. Further, external review is a very important protection and allows you to get an unbiased, independent opinion.

As follows is a successful appeal scenario provided by Thomas LaBorde, CPA CIA, Business Manager for LaBorde Theray Center in Lafayette, LA. LaBorde successfully resolved a poor quality external review by citing regulatory review standards. This type of approach requires payers to look at review processes for compliance with quality standards.

Submitted by Thomas LaBorde, CPA CIA, Business Manager for LaBorde Therapy Center in Lafayette, LA:

We recently have been appealing a denial for Medical Necessity for about 7 Physical therapy visits. We have been fighting for months and we were at our last level of appeal. We had been denied by 2 external Reviewers. I was browsing through the database to see if I could come up with anything else and found the “Request for Review by Qualified Reviewer.” You see both external reviewers were Internal Medicine. We sent the letter and requested a review by a Physical Therapist. Within a week the claims were paid.

As follows is the letter content from used by LaBorde for this successful appeal:

Dear Director of Claims,

It is our understanding that this treatment was denied pursuant to medical necessity or other specialty care policy or plan coverage limitations. Your initial decision states that insufficient medical information was provided to support the treatment and the denial was upheld. Please accept our appeal of this adverse determination.

We appreciate that it appears that your initial review was conducted by a physician, nurse practitioner, or other unidentified Appeals Specialist. However, it is our position that an adverse benefit determination based in whole or in part on a medical judgment involving specialty-care treatment must involve a consultation with a board-certified physician in active practice and familiar with this treatment/procedure. A clinical peer is defined by the Utilization Review Accreditation Commission (URAC) as a physician or other health professional who holds an unrestricted license and is in the same or similar specialty as typically manages the medical condition, procedures, or treatment under review. Generally as a peer in a similar specialty, the individual must be in the same profession, i.e., the same licensure category as the ordering provider. Further, peer reviewers in active practice generally have the advantage of experience with integration of clinical treatment standards into daily medical decision making.

If a review by a physician in active practice is not provided, it is your duty to demonstrate that a quality medical review was provided. Therefore, we request the appeal reviewer’s detailed response regarding his or her qualifications, familiarity with the treatment in question, reliance on published clinical guidelines and recommendations regarding alternative care which would be covered under the policy or plan benefits. This information would allow us to fully assess the basis of the decision and determine applicability of standard treatment protocols to this patient’s unique medical condition.

If your response does not demonstrate an quality medical review, we maintain our request for payment of this claim. If benefits remain denied, please provide all of the above referenced information so that we may assess the quality of the medical review and determine our rights in regards to this matter.

Claims Analyst

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