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Archive February 2018 XIX, No. 2

Coding & Billing: Yes, You Can Overturn Medical Necessity Denials

3 keys to challenging - and collecting on - unfair claim denials.

Tammy Tipton

Tammy Tipton


Medical Claim
ON APPEAL Do you understand your legal rights and how to argue those rights effectively when insurers uphold medical necessity denials unfairly?

Three words no surgical facility leader wants to hear: not medically necessary, a derivative of medical necessity — the quasi-clinical term that payers have a hard time defining but won't hesitate to reach for when they want to say denied.

Of course, you can appeal an insurance claim denial based on a medical necessity decision, but when's the last time you took the time and trouble to do that? If you're like most administrators, you won't challenge a payer's decision — even when you suspect an insurer is upholding denials unfairly. Too much time. Too much effort. Well, you're right. It takes dogged determination, but medical necessity denials get overturned over and over. Here are 3 keys to collect on unfair medical necessity denials.

1. Review payer's "medical necessity" documentation. Payers are forever asking providers to provide documentation. But payers, too, must have written clinical criteria on which they base medical necessity. Most states have consumer protection laws that require the disclosure of the clinical criteria used in making treatment decisions. Regardless of your state's laws, ask insurers for clinical criteria so you can review it for relevance and accuracy. Obtaining the criteria lets you develop a better argument around why payers should make exceptions to this type of guidance. For example, after you discover which patient populations the criteria does and does not apply, you might be able to question the guidance on the basis of its suitability for complex patients and understudied patient populations.

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