Carriers have a responsibility to provide detailed responses to utilization review requests. Further, when adverse determinations are given, many consumer protections require the carrier’s written denials to explain the clinical criteria supporting the decisions and provide appeal information.
Unfortunately, many denials are silent on the issue of alternative covered options. Providers, case managers and patient advocates must aggressively pursue carriers with demands that adverse determination include information on the treatment alternatives available under the coverage terms.
“Physicians give information to patients not only to help patients make decisions but to promote trust, which has both intrinsic health benefits and instrumental effects on health by inducing patients to share relevant facts about themselves with their providers and improving compliance with therapy,” explains William Sage in his expose on managed care medical necessity decisions entitled Managed Care’s Crimea.
“In particular, when doctors convey their professional opinion that a specific therapy is not advisable, they also maintain hope, offer explanations and alternatives, and assure patients that they will not abandon them. Health plans should try to follow this example when relaying determinations of medical necessity or other coverage matters. For example, written and oral communications denying coverage or requesting information should be compassionate, should be forthcoming about reasons for the health plan’s action, should take responsibility for the consequences instead of disclaiming them in anticipation of litigation, should offer alternatives to denied treatment, and should avoid giving the impression of abandonment.”
Utilization review appeals can include a demand that the carrier reconsider the original denial or detail available treatment options in writing. As part of such a request, it can be worthwhile to demand peer-to-peer review so that the treating doctors can both explain the justification for the denied treatment and explain any quality care concerns related to the carrier’s recommended course of treatment.
Peer to peer reviews are often not pursued simply due to time constraints. However, your request for peer review can specify a time in hopes that the carrier will work around the time constraints of a busy practitioner. Set a suggested time and make your demand using language such as the following:
We are in receipt of your recent adverse determination and wish to schedule peer discussion to discuss the denial. As you are likely aware, peer-to-peer conversation regarding treatment provides an opportunity for the face-to-face treating medical professional to discuss the reasons for the initially prescribed treatment, unique medical factors complicating the treatment plan, clinical standards of care and available treatment options which are covered by your company. 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. Dr. (insert name of ordering provider) is available for peer discussion on Tuesdays from 3 to 4 p.m. CST. Please have a clinical peer call Dr. (name) at that time to discuss this patient’s care.
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