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Quality of Appeals Reviewer

Are your appeals getting a response from a Qualified Appeals Reviewer?

Urologists don't recommend patients for open heart surgery.  So should a urologist hired by an insurance company be allowed to make utilization review or appeal decisions related to cardiology treatment for an insurance company?

Keep reading to find out how to ensure your appeal reviews are conducted by qualified personnel.

Specialty Highlight: Assistant Surgeon

A number of different specialty care providers are reporting a high rate of denials on assistant surgeon claims.

In appealing assistant surgeon denials, it is important to require the insurance company to clarify if the denial is based on specific policy exclusions, medical necessity limitations or the credentials of the assistant surgeon.

You will also want to cite any recognized industry standard regarding reimbursement of the charges, including Medicare reimbursement policy, even if the coverage is not bound by those standards.  Although Medicare reimbursement policy is not necessarily binding on commercial medical claims, it can be persuasive information in the absence of a clearly-worded exclusion. Finally, it is important to explain exactly what services the assistant surgeon provides during the course of surgery and the skill level necessary to perform the required tasks.

We have a letter under the Topic "Medical Necessity," Subtopic "Medical Necessity By Condition," which assists users in appealing denials for assistant surgeon charges on gastric bypass claims.  Look for the letter titled "Gastric Bypass - Asst Surgeon Charges."

While your claims may be for different procedures, this letter serves as a guide on how to customize an appeal letter related to other procedures.  Any questions or comments about how to best customize this type of letter for a different procedure can be posted to the AppealLettersOnline.com Users Forum specific to your specialty.

Letters appealing assistant surgeon charges should also routinely include the operative report and the assistant surgeon's medical license information.

Access the appeal letters at AppealLettersOnline.com

Specialty Highlight: Chiropractic Benefits

Manual manipulation is the one covered chiropractic benefit under Medicare.  Despite the coverage, claims for manual manipulation are still reviewed for medical necessity and for billable diagnoses.  In the event of a denial for lack of medical necessity, chiropractic providers should submit the medical records to substantiate the medical necessity of care.  This type of appeal is also more persuasive if the CMS medical necessity requirements are cited and the chiropractor explains in detail how the patient's condition met the requirements.  We have a letter citing the CMS medical necessity requirement for manual manipulation which is the following:

"The patient must have a significant health problem in the form of a neuro musculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient's condition and provide reasonable expectation of recovery or improvement of function. The patient must have a subluxation of the spine as demonstrated by x-ray or physical exam, as described above."

The letter is available in the AppealLettersOnline repository under the Topic: Medical Necessity, Subcategory: Medical Necessity Denial By Condition under the letter title "Manual Manipulation."

Access the appeal letters at AppealLettersOnline.com