Appeals involve highly technical issues such as clinical guidelines, specialty coding standards, quality of care and contract requirements. It takes a highly qualified appeal reviewer to respond appropriately. However, carrier appeal responses fall short again and again. In fact, many carriers appear to send appeals through the same automated process which initially resulted in a denial. Computers are not good at appeal review. Providers and patients deserve quality appeal reviews and the law is on their side.
Medical billing professionals must demand that appeal reviews be conducted by a qualified, credentialed reviewer. When an appeal review is conducted by an unqualified or unidentified reviewer, the Level II appeal should discuss the importance of the qualification of the reviewer. Further, to insure a professional response, it is also beneficial to cite any potentially applicable appeal review protections such as the following:
- State utilization or appeal review laws which specify the appeal reviewer’s qualifications.
- ERISA’s expert review requirements contained in the ERISA Claim Procedure Regulation.
- CMS appeal guidelines requiring medical necessity denials to be reviewed by a panel of physicians or other appropriate health care professionals who have sufficient medical, legal, and other expertise, including knowledge of the Medicare Program’s beneficiary quality of care protections. Further, up-to-date medical, technical and scientific evidence must be considered to the extent applicable. Source: 42 CFR Parts 401 -203.
- Industry standards such as the Utilization Review Accreditation Commission. URAC states that UR appeals should be reviewed by a clinical peer defined in the published standards 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.
Many medical providers feel that carriers should involve appeal reviewers in active practice. While this is not a protection specifically referenced in most appeal review mandates, it is a viable argument in your appeal if you believe the denial involves medical decision making issues more familiar to a practicing healthcare professional.
We recommend the following wording for seeking a review by a health professional in active practice:
We appreciate that it appears that your initial review was conducted by a (insert type of professional or title, ie licensed physician, nurse practitioner, or Medical Director, Appeals Specialist). However, it is our position that an adverse benefit determination based in whole or in part on a medical judgment involving this type of 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 recommendation 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.
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