Specialty care medical appeals often involve complex clinical information. Hours can be spent crafting a detailed explanation regarding the treatment provided and current specialty care standards.
One of the ongoing challenges of specialty care appeals is demanding a professional review of the complex specialty care information such appeals involve. Specialty care appeal review requires insurers to employ a broad array of specialty care reviews and ensure that such reviewers apply up-to-date specialty care clinical criteria. Often, specialty care denials do not adequately assure specialty care practices that a high quality review of technical specialty care information has been provided.
Specialty care appeals should always contain clear wording demanding that, if a claim denial is upheld, the appeal reviewer must disclose any specialty-specific criteria used in the appeal review and provide detailed information regarding their qualifications to review such claims.
Appeal Solutions has developed a number of “appeal review demands” which are particularly applicable to specialty care appeals, including the following demands which assist specialty care providers with obtaining information to assess the quality of the review process provided by the carrier:
(1) Demanding Disclosure of Specialty-Specific Coding Rules – Specialty care appeals are often reviewed by insurers for compliance with specialty-specific coding rules. It is important to demand disclosure of the source of the coding rules so that your office can assess the source and the date of such coding information. You may be able to provide additional information regarding the reliability of such information or updated information the carrier has not incorporated into the review process.
(2) Demanding a Review By A Certified Coder – Another approach to take on specialty-case coding issues is to demand a review by a certified coder familiar with the specialty coding in question. Your request can state that “It is our position that appeals involving specialty-care coding should be reviewed by a certified coder with recent training in the specialty coding in question. Therefore, please provide the name of the certified coder involved in this review, the licensing organization and a description of any additional training involving (insert specialty – ie, orthopedic) coding obtained by the reviewer.”
(3) Demanding Disclosure of Specialty-Specific Clinical Review Criteria – Specialty-specific clinical review criteria often dictate the types of treatment available to the patient during treatment. For that reason, it is imperative that carriers disclose clinical review criteria and openly discuss situations where the review criteria may not have been appropriately applied. In particular, any medical necessity appeals should include wording requesting that the carrier release the clinical review criteria and when that criteria were last reviewed and updated.
(4) Demanding Peer-to-Peer Review – Peer to Peer review is one of the most recognized components of a quality review process. Further, demanding peer conversation allows the treating physician to interact with the carrier decision maker and point out any potential risks to any alternative treatment under consideration. Many states include peer review requirements in the utilization review mandates and the Utilization Review Accreditation Commission Standards require member organizations to provide peer conversation when requested by the treating physician. Specialty care appeals can suggest a time for peer conversation or state that arrangements can be made with the treating physician’s administrative assistant. However, it is important to put your demand for peer review in writing with the carrier.
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