Strategic Planning: Turn around denials

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Wednesday, June 10, 2020

Q. How do we keep orders moving forward and help our authorization department turn around medical necessity denials during the COVID-19 emergency? 

A. In response to the public health emergency, CMS approved the use of telehealth to improve patient access to equipment. With patients still fearful about going to the physician’s office, this practice looks likely to continue.

Fortunately, physicians are getting comfortable with telehealth and seeing patients using FaceTime, Zoom, Messenger or other tele-video methods.

This doesn’t mean authorizations will always go through. If the insurer denies your authorization, there are several options for turning it around.

1. The patient can call and speak with a clinical reviewer.  2. You can request a re-review process where you can submit additional information that might support medical necessity. 3. You can have a peer-to-peer discussion with the client’s doctor and the insurance company’s medical director.

Reach out to the physician to see if they would be willing to assist the patient in turning the denial around. Let them know the options they have in the appeal process. The doctor can submit additional backup and/or write an appeal letter. 

If the doctor is on board, send them the original submitted authorization packet, including the insurance denial to him/her. List all the reasons why the client's equipment was denied. Now the doctor is prepared and can address each and every reason with the client.  

Have the doctor's office schedule a tele-visit with the client to address all issues listed and have the doctor document in their chart notes. Now he is prepared to write an appeal letter or conduct a peer-to-peer discussion.

Written appeals can take up to 30-45 days. 

Bill Paul is CEO at ATLAS-RPM Professional Services. Reach him at bpaul@ATLAS-VUE.com.