Using URAC To Curb Denials And Appeal Claims

The American Accreditation Healthcare Commission/URAC has established rigorous standards for utilization review which many carriers must follow. The standards were developed to ensure that appropriately trained clinical personnel conduct and oversee a timely and responsive utilization review process and that medical decisions are based on valid clinical criteria. The standards apply to accredited members of URAC and to organizations which fall under state mandated URAC compliance.

Some of the more protective aspects of the standards are not widely known among medical providers and, therefore, carrier noncompliance to URAC standards is not widely tracked and its seriousness is not fully understood. However, instances of noncompliance can seriously compromise the carrier’s ability to defend a denial because, much like our justice system, any failure to follow established procedures for every participant in the process indicates an inherent unfairness in the process. If the process is not conducted consistently, then the results become suspect. As a result, carrier noncompliance to utilization review standards is a very valid argument for requesting a higher level of review and, ultimately, reconsideration of subsequent denials. Further, noncompliance should be considered at each managed care contractual negotiation and ongoing problems brought to the attention of compliance officers for the carrier.

FAILURE TO PROVIDE PEER REVIEW WITHIN ONE DAY OF DENIAL

URAC Standard 22 requires that any refusal of certification be followed by the opportunity for the attending physician or ordering provider to review the clinical information with a clinical peer with the same training as the requesting physician or provider. If a request for peer-to-peer review is made, the conference must take place within one business day. Further the clinical peer must be 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, the individual must be in the same profession, i.e. the same license category as the ordering provider. The Commission states it strongly believes that a good faith effort must be made by UM organizations to achieve the objective of informed discussion between the providers and reviewers of services and, to this end, it requires that decisions not to certify only be made by clinically qualified (same licensure category and board certified) as the physician or provider recommending treatment.

FAILURE TO GIVE WRITTEN NOTICE CITING “PRINCIPAL REASON(S)”

URAC Standard 31 requires that notices of non-certification decisions must state in writing the principal reasons for the decision. Further a principal reason must be a clinical or non-clinical statement describing the general reasons for the non-certification and must be more detailed than “lack of medical necessity” and the clinical rationale must be provided upon request.

ISSUING OVERLY BROAD MEDICAL RECORDS REQUESTS

URAC 44 states that organizations conducting prospective, concurrent and retrospective review must only collect information necessary to certify the admission, procedure or treatment, length of stay, or frequency or duration of services. Organizations are prohibited from requiring hospitals, physicians, and other providers to numerically code diagnoses or procedures before consideration for certification. Further, if medical records are requested, organizations are directed to be specific regarding what portion of the medical record is required.

FAILURE TO ABIDE BY REQUIRED DEADLINE

URAC Standard 6 requires organizations to respond to communications from providers and patients within one business day. An initial UM decision must be made on prospective review within 72 hours of a request involving urgent care and within five calendar days of a request involving non-urgent care. Retrospective review decisions must be issued within 30 calendar days of the request and concurrent review must be decided in 24 hours of the request for urgent care and four calendar days of a request for non-urgent care (Standards 24-26). Standard appeals must be completed in 30 calendar days of the appeal and expedited appeals must be completed no later than 72 hours from the initiation of the appeal (Standard UM 41).

HOW DO I DEMAND COMPLIANCE AND USE NONCOMPLIANCE IN APPEALS?

URAC provides education opportunities and onsite inspections in an effort to ensure compliance with these standards. They also review complaints filed against members. However, your best protection is awareness. If you are aware of the standards that must be followed and cite the standards in phone calls and request letters to the carriers, you will establish your office as progressive, informed and unwilling to accept a poor quality review of requested treatment.

Step 1 – Download the URAC Health Utilization management Standards. Read them yourself. The State of Illinois is one entity that has enacted URAC compliance for UR companies operating in the state. They provide an online copy of the standards to encourage consumer use. Go to www.ins.state.il.us/URO/URAC_standards_4-1.pdf to download a personal copy.

Step 2 – Find out if your state recognizes URAC accreditation. Even if they do not, the majority of the major insurance carriers are accredited organizations that have voluntarily agreed to the guidelines. A member directory is available at URAC.org and also contains information for each organization’s compliance contact person to whom complaints should be made regarding noncompliance issues.

Step 3 – Make it a point to request peer-to-peer conversation on any certification denial and remind the carrier of the 24-hour deadline. If the carrier does not provide peer review as required, explain that this noncompliance seriously compromises their ability to defend any noncertification if an appeal is filed with the state independent review process or if the matter is litigated. Routinely note in patient records any noncompliance with URAC guidelines. (See Peer-To-Peer Conversation Request Letter Under Medical Necessity/URAC Regulations in the AppealLettersOnline.com letter repository.)

Step 4 – Always require carriers to provide written notification of a certification denial and specify that you are particularly interested in the principal reason(s) for the decision. You may have to actually provide URAC’s definition of principal reason that makes it clear that “lack of medical necessity” is not an adequate response. (See Lack of Written Decision letter Under Medical Necessity/URAC Regulations in the AppealLettersOnline.com letter repository.)

Step 5 – Review medical records requests with a sharp eye for unnecessary and overly broad requests and again, do not hesitate to send carriers actual copies of the URAC standards when you feel the carriers are not in compliance. (See Records Request Response letter Under Medical Necessity/URAC Regulations in the AppealLettersOnline.com letter repository.)

Step 6 – Review any non certification or unfavorable appeal responses for compliance with URAC decision deadlines. Every appeal letter regarding the treatment should include a reference to any failure to respond within these time frames. Make it clear that the ordering physician does not have the benefit of such leisurely reviews. (See Lack of Timely Decision and Lack of One Day Response letters Under Medical Necessity/URAC Regulations in the AppealLettersOnline.com letter repository.)

And if that does not work . . .

URAC.org has online complaint filing. Member profiles also list executive level representation from member organization who are responsible for compliance. Send complaints directly to compliance officers with the carriers.