Successfully appeal an insurance company reviewer decision

Coverage requests get rejected when the requested service does not fit within an insurance company’s initial guidelines for approval.

This happens for a number of reasons, but usually it comes down to poor documentation or inappropriate care, or in some cases care that is appropriate but can’t be supported in the literature.  When a denial occurs, the physician or patient has several opportunities to appeal this decision.  The first appeal is about proving that your case does meet the insurance guidelines and that it was incorrectly rejected.  The second appeal is about proving that the request should be accepted outside of the coverage guidelines.  Sometimes there is another level that looks at whether the care is experimental.

The job of the reviewer is to look at the data provided and determine if the case meets insurance guidelines, or if the review is outside of guidelines, to determine if the requested service is supported by peer reviewed medical literature.  The reviewer is a physician with a busy practice, and only has a certain amount of time that can be dedicated to the review (usually less than an hour.)  Anything you can do to make this job easier will help your appeal be successful, and anything you do to make this job harder may hurt your appeal.

The following are things you should do or not do when writing an appeal to maximize your chance of approval.  In fact, if you nail these things, every appeal will be accepted.

Things you should do

Write a summary letter. The reviewer is trying to look through your medical records and figure out what you are trying to do.   If they have to look through piles of semi-illegible notes and try to put it all together, they may come up with the wrong idea.  It behooves you to write a letter that summarizes the care of the patient, including presenting symptoms, workup performed so far, previous treatments done and response to those treatments, current diagnosis, and what is planned.  Do not make the reviewer put this all together on their own.

Answer the phone! If a peer reviewer calls you, for god sakes please answer the phone.  Tell your staff that they should get you for these calls.  The person calling you is a doctor who is probably trying to call you between patients.  They have a limited amount of time to turn the review over, and if they need information and can’t get it, you are going to be rejected.  You must assume that if a reviewer is trying to call you, they didn’t have enough information in the provided records to approve the case.  If the call doesn’t happen, the appeal is going to get rejected.

Be a good documenter. It goes without saying that if your notes are crap, its very tough to win an appeal with them.  If you aren’t a good documenter and are losing appeals, this is probably why.   This doesn’t mean you have to write a novel.  It just means you have to include important information and justify what you want to do.  “Patient has heavy bleeding for two years and has fibroids. Plan: hysterectomy” NO!  “46 year old with menorrhagia and anemia for 2 years, 16 week size fibroids uterus.  We discussed various therapies including medical and conservative surgical options, and she would like a hysterectomy” – YES!  That’s all you have to say.  It is this reviewer’s sadness that too many physicians don’t take the time to write even this much.  Corollary: if you are appealing and realize your notes are crap, write a really good letter, which makes the notes unimportant.

Practice evidence based medicine. If you are trying to do something that can’t be supported in evidence, its going to be hard to win an appeal.  A good example is a subcutaneous terbutaline pump.  Its nearly impossible to win an appeal for this, because the reviewer can’t quote any literature that would support an approval, even if the reviewer thinks they work.  The corollary to this is that if you are doing something that is somewhat controversial and are appealing a rejection, it really behooves you address that controversy in your appeal letter, preferably with peer reviewed sources to justify your point of view.  If you make a good sourced argument, there is little to keep the reviewer from just using your argument and your sources to approve the case.  This may seem onerous, but in reality it is a good thing to be doing anyway for your own doctorhood.   If something is getting rejected, and you sit down and try to justify it and find that you can’t, perhaps what you are doing wasn’t right in the first place.

Limit what you send in. It is far better to send in the 20 pieces of paper that justify your case than 200 pieces of paper that mostly consists of irrelevant documentation.  Include your letter, your clinical notes — about the condition at hand — labs, and path and imaging reports.

Things you should not do

Don’t be a jerk. My god, how many doctors don’t get this!  Some doctors think that by berating the reviewer they are going to get approved.  Oppositeland, people.  If a reviewer calls you, its because your chart didn’t have enough information to approve the case, or they didn’t understand what you are doing.  If the you get on the phone and decide to unload on the reviewer about what you thinks of the insurance company / the reviewer / the patient / how medicine is going to hell…  it really hurts the case.  The reviewer is a doc that is probably trying to fit this call between patients.  They just want the facts, doc.  In my experience, being berated by a doc doesn’t really affect the review directly, but it really gets in the way of getting the information.  “DO YOU WANT TO SEE MY PATIENT AND TELL ME I’M WRONG!!! IS THAT WHAT YOU WANT!!! TELL IT TO MY FACE!!”.  Not productive.

Check your ego at the door. And by this I mean, don’t assume that medical necessity is defined strictly by what you think is medically necessary.   I read so many appeal letters that say “Jill needs X because it is medically necessary for her condition.”   This is worthless.  The appeal is not a note from the doctor getting Jane out of work for the day.  If the fact that there exists a doctor that thinks that X is medically necessary were sufficient, nothing would ever get rejected and there would be no need for an appeals system.  Maybe some doctors would like this, but it is a recipe for a bankrupt medical system.

Insurance companies ration care.  It’s what they do.  They do not assume that just because you think it is necessary that it actually is, and perhaps more important to understand, they do they allow reviewers to make arguments on that basis.  Your appeal letter must describe and defend your case.   Don’t take it personally, its just the way the appeals process works.

Don’t write illegibly. And if you do, type or dictate your notes.  A pile of illegible papers does not a good appeal make.

Don’t quit after one appeal. If you get rejected once but you really believe in the issue, appeal again.  Remember, its not until a second appeal that the case gets considered outside of insurance guidelines, or when something that could be considered experimental might get approved.  If you always quit after one attempt, lots of things that might get approved don’t.  Is this system designed to approve fewer things?  Maybe.   But if you want to win, you have to do it twice.    If you write a good appeal letter the first time, there is no reason you can’t just send in the same appeal again.  If what you want to do is a little grey, your justification of what you want to do may not even get considered until the second appeal, because the first review is just about guidelines.  A good example would be using a novel chemotherapeutic for recurrent ovarian cancer. If it doesn’t fit the guidelines (which are still pretty good documents – see part 1), it probably won’t go through on the first appeal.

Don’t have your patients write appeals. While patients write passionate appeal letters, they almost never have useful information in them.   The kinds of things that patients write have almost nothing to do with the appeals process.  The fact that they paid their premiums for years and are super pissed that X was not paid for is completely irrelevant.  The only thing a patient can do that is helpful is to describe the case better than it was described in the medical records.  If your records are good, this shouldn’t be an issue, and usually patients have a hard time describing the case in an objective way.  A patient can almost never actually defend the medical care, which is usually what is needed, because they don’t have the background to do it.

And if you really want to be a master of winning appeals, become a peer reviewer.  In the four years that I have been doing this, not only have I made extra money, but I have learned this system inside and out.  It has given me a better understanding of what it takes to really justify what one is doing, and in doing so has made me a better doctor.  I have a much better idea of what will go through and what will be scrutinized, and can explain those things to patients in a way that makes sense.  It has also forced me to keep up on the literature in my field, even in areas that I might not typically read in.

When good doctors become peer reviewers, they help the system work the way it should.  Maybe you should do it too!

Nicholas Fogelson is an obstetrician-gynecologist who blogs at Academic OB/GYN, where this article originally appeared.

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  • Chad

    I am concerned about the physician reviewer behavior. This may not be an ethical behavior for a physician. To form a patient-physician relationship by reviewing a patients information and then declining to approve a prior authorization can and does impact patient care. When this occurs without the reviewing physician examining the patient, taking a history or reviewing the full chart and data, this may infact be an act of negligence. It most certainly is a conflict of interest to be paid by the insurance company for whom the case is being reviewed.

    I don’t have any problem with rationing care out in the open, but covert rationing of this nature should be disallowed.

    I would be happy if the system was changed so that the reviewing physicians could be held accountable for their decisions, just like a practicing physician is through the tort system when they make medical judgments.

    • http://www.academicobgyn.com Nicholas Fogelson, MD

      >> I don’t have any problem with rationing care out in the open, but covert rationing of this nature should be disallowed.

      I completely agree. Dr Rich fan?

      • Chad

        Dr. Rich is an excellent blogger.

  • http://amjmed.blogspot.com Pamela Powers

    Great advice. Many of these do’s and don’t's could also apply to physicians submitting a manuscript or case study to a journal: Check your ego at the door; don’t write illegibly (or unintelligibly); don’t be a jerk; limit what you send it; practice evidence-based medicine; and be a good documenter.

    I would add one other item– follow the directions. This seems simplistic, but it’s surprising how many people get huffy with processes and staff when if they had only followed the directions in the beginning, everything would have gone much smoother.

    Pamela Powers, MPH
    Managing Editor, American Journal of Medicine

  • pcp

    Where to begin? OK, I’ll start with:

    “Answer the phone . . . The person calling you is a doctor who is probably trying to call you between patients”

    I could fly a 747 through the double standard the author is proposing!

    • http://www.academicobgyn.com Nicholas Fogelson, MD

      So true, but the original statement is the truth. If a reviewer needs to talk to a doc to clarify something, the appeal won’t succeed if no contact can be made.

      • pcp

        And if the doc needs to talk to the reviewer to clarify something, the treatment may not succeed if no contact can be made.

  • soloFP

    Most of the initial MRI requests are simply taken by a person with no medical background who checks off boxes on a form that decide if the study will or will not be approved. If you are really nice to the person, the checker will ask you questions that are loaded for yes and approval answers, such as, has the patient had an xray of the body parts, tried physical therapy, and NSAIDS. I also find that the beginning and end of the day are the best times to get through quickly and to get approvals. Often I do the prior auth process with the patient in the room and the insurance company-contracted reviewer on the phone.

  • Smart Doc

    This is the wave of the future: rationing care through total torture of the doctors.

    For a big surgical case approval, it is worth the battle.

    For the endless small case fights, it is simply not possible,

  • http://www.healthandsafetytrainers.ca/ safety trainers

    The fact that they paid their premiums for years and are super pissed that X was not paid for is completely irrelevant. In the four years that I have been doing this, not only have I made extra money, but I have learned this system inside and out. It has given me a better understanding of what it takes to really justify what one is doing, and in doing so has made me a better doctor. When this occurs without the reviewing physician examining the patient, taking a history or reviewing the full chart and data, this may infact be an act of negligence. It most certainly is a conflict of interest to be paid by the insurance company for whom the case is being reviewed. I would add one other item– follow the directions. This seems simplistic, but it’s surprising how many people get huffy with processes and staff when if they had only followed the directions in the beginning, everything would have gone much smoother.

  • http://supremacyclaus.blogspot.com Supremacy Claus

    Evidence based medicine is the medicine of 7 years ago, after academia has caught up with their research paper shuffling. It represents deviations from current standards of due care, but a convenient pretext to deny care by traitors to clinical care.

    Appeals are totally rigged against spending by insurance, and phony time consuming procedures.

    Here is another idea to get approval.

    Keep submitting or calling about approval. Eventually, a low level reviewer will randomly approve the request. Most of the decision are inappropriate and driven by personal profit from denial of care. This doctor should tell us whether he gets bonuses from company profits.

    Here is another idea. Have a standard letter to be signed by a patient. When these insurance company collaborators deny adequate care, send a formal request for an investigation by the licensing board. If the doctor is out of state, not licensed in the state of the patient, the denial of care is a medical act, requiring a license. Submit a request for an investigation into the unauthorized practice of law. If the doctor is licensed in the state of the patient, but qualified outside the specialty of the prescriber, ask for an investigation into practice outside the scope of training and knowledge. If the reviewer is licensed in state, and deny care within his own specialty, ask for an investigation into a medical act taken without direct evaluation of the patient, on an unknown patient. Records are not transcipts, so they are not adequate substitutes for a thorough evaluation in person by the reviewer. Worse, the letter should ask whether the doctor’s pay will increase or decrease from his decision to deny care. If there will be a difference in pay, refer to the Department of Justice for a violation of the Stark Amendment and Anti-Kickback statutes.

    To deter.

  • http://supremacyclaus.blogspot.com Supremacy Claus

    Sorry. Not the “unauthorized practice of law” (above). The “unauthorized practice of medicine.”

  • http://www.academicobgyn.com Nicholas Fogelson, MD

    >> This doctor should tell us whether he gets bonuses from company profits.

    The nature of the third party review process is that the reviewer is a physician in practice, not an employee of the insurance company. The reviewer is paid to review the chart, irrespective of the results of the review.

    • Chad

      Ah, but who pays the bills, and would you continue to get asked to review if you didn’t come back with favorable results?

      How much is the going rate for a review these days anyway?

      • ninguem

        thirteen pieces of silver

  • http://www.healthharbor.com George

    As much as insurance denials waste everyone’s time, the author is correct that the denials can be overturned. The key is to have an effective physician / patient tag team. I don’t disagree with anything that was written, but the other point of leverage is to have patients contact their HR or Benefits department, which can often put good pressure on an insurer as the “real” buyer of the health plan policy.

  • Internist

    I am an internist seeing patients full time and do reviews for an insurance company. You would not believe the number of scans ordered for patients that are totally unnecessary. 3 days back pain with normal exam- order an MRI. Oh, by the way, the doctor owns the machine so she makes a ton of money doing the scan. If the patient failed therapy, or has a neurologic deficit, it gets approved. Treating cancer should be based on guidelines, not on the profit to the doctor for picking a certain drug. Same with most diseases- most brand name drugs are no better than generics, but the doctor does not get a free dinner from the generic company. And of course how many people died from Vioxx and Avandia? No better than motrin or metformin but much more profitable.