Don't Panic: You Can Navigate the River of (Insurance) Denial

It has happened to all of us at one time or another. We have received that letter or C9 over the fax or in the mail stating that our proposed treatment is denied.

This is usually followed by some vague rationale such as "not medically necessary", or in the case of the injured worker, "treatment exceeds ODG(Official Disability Guidelines). These are actually quite favorable to chiropractic, but more on that later. The letter arrives and we fume and rant about these "so and so" insurance companies and MCOs(managed care organizations). How many of us really stop, breathe, and prepare for the battle ahead? Less than 50% on average. We grumble, accept defeat and inform the patient that they must now pay cash.

It does not have to be this way, and in truth, if we really care about our patients as deeply as we say we do, then we owe them more. "But I don't have the time to chase down every denial" you say. It takes far less time than you think. Below I will outline some very easy ways to compartmentalize and deal effectively with the denials that are destined to come over our fax machines and through our mail boxes.

And, what so many fail to understand in their disappointment or anger over a denial is that you can turn what may seem like a weakness or an obstacle into a strength. And win.

Basis of Denial Determines Your Response

The first thing I always address is the rationale for the denial.

There is usually a medical reason i.e. "not medically necessary", or a legal/procedural reason, such as "treatment has exceeded allowed number of visits" etc.

This first step is crucial, as it dictates which path you must then traverse to get your medically necessary care approved and paid. The first of these paths we will discuss is the medical path. For instance, did you know that simply stating "not medically necessary" does not qualify as a rationale for denial of treatment?

The party making the denial must produce a written medical review performed by a peer. This must be done when the "NMN"(not medically necessary) denial is penned. If the document cannot be produced, then the insurer has other problems. Be sure when going through the denial process, that small errors are not over looked. Errors in coding and modifier attachment will cause denials of service and can send you on wild goose chases.

Another factor to consider is that many third party payers are utilizing intermediary services to manage their claims. All the large insurance companies are doing this and more will follow. Many doctors I know look at these groups as obstacles. They all require varying degrees of paperwork and if filled out properly, this will open the doors to communication.

I recently enjoyed a pleasant conversation with a Doctor from one of these groups who had initially denied my treatment plan. I called and politely left a message stating who I was, who the patient was, and how I looked forward to discussing my treatment with the reviewing doctor. In closing, I requested that he have available the guidelines utilized in making the denial. This immediately set the tone for the follow up conversation whereupon, my treatment plan was approved.

Getting Your Facts, and Theirs, Straight

The absolute key when dealing with a medical dispute, is to have all the facts in front of you. You must know what guidelines are being reviewed to determine necessity of care. You must learn them front to back and back to front. This may seem like a lot of extra effort. You are right. If you want to see third part patients, this is what you must do if you wish to be fairly compensated.

This will also help you determine whether you have an argument from the very beginning. If the accepted guidelines the third party is utilizing tell you that you cannot do something and be compensated for it, then you are better off putting your energy elsewhere.

Understand, I am not discussing whether a third party should or should not pay for a service. That is between you and the patient. What I am gingerly telling you, is that if the guidelines you agreed to follow when you signed the contract with the payer do not support the service, then you need to focus on changing the guidelines.

Knowing the rules cold will always place you at an advantage when speaking to a third party payer. You do your patient a disservice when you do not spend the time to do this.

Do They Even Know Their Own Rules?

The second, and probably less interesting to most doctors, is the legal or rules based rationale for the denial of care. All of you, stop rolling your eyes. I know most of you did not go to law school. Still, this is one of the most overlooked and easily utilizable methods of getting care approved.

Trust me, you want to read the next section. The reason this is often easier, is the fact that very few people on either side know the rules.

Knowledge is power? In this case, knowledge may represent absolute power.

I will use the Bureau of Workers Compensation in Ohio as an example. In Ohio, we still retain a "state funded" system, but it and the self insured companies are represented by MCOs or managed care organizations. These groups determine whether or not to approve and pay for treatment you have requested. There are, in Ohio, a very specific rules set for the determination of medical necessity. In Ohio, MCOs utilizes the Official Disability Guidelines to determine medical necessity.

[pb]What does this have to do with legal and rule-based arguments? Well, anyone who utilizes ODG as a rationale for denial must cite the guideline which has been exceeded.

If they do not, the review is in serious jeopardy of not being utilized. That is, if someone (you) who knows the rules makes the governing body in charge aware of the violation.

This leads to another truth you must all recognize and understand; the governing bodies in charge do not always know the rules. Sometimes, they must be instructed. Do this for your patient.

As an example, let us return to the BWC example for a moment. Reviews are performed by doctors regularly as an attempt at peer review and oversight. This is not always successful. It is not uncommon that a review will come back denying care based on a host of reasons; "treating non-allowed conditions", "no lasting therapeutic benefit", "care exceeds established guidelines", and the list goes on.

What many do not know is that none of these reasons, in regard to the Ohio BWC, are allowed to be used in the determination of care allowance. I don't mean to suggest that every state's BWC program follows these rules. It is merely a way to show you the power of such knowledge. Understanding the systems within which you work and knowing the rules and how they are used both for and against you is paramount to maximizing the therapeutic benefit your patient receives.

Let us switch gears for a moment, back to the national third party payer system. Insurance companies nationwide all have rules they are legally obligated to follow for the determination of care. This does not prevent them from listing some of their own "arbitrary controls" as rules.

As referenced in a previous article I wrote, when your company purchases a plan for its employees, that plan must be upheld and followed to the letter. This is not always done.

The largest oversight usually revolves around the maximum number of visits allowed by the plan. Many now contain visit limits. Some base the need on medical necessity. It is important to know which each plan involves. This saves you time and money and, more importantly, keeps you from plumbing a dry well.

If the patient has 12 visits allowed in the summary plan document, then that is what they have and no amount of appeal will be successful. You may have gathered that oftentimes you will find that a service is a covered benefit and is being denied as though it is not.

This "oversight" is common within the system and only knowing the rules and being able to accurately quote them will allow you to prevail in the determination of treatment or care allowance. Sometimes, it is as simple as calling the third party payer on the phone, making them aware of the oversight and solving the problem right then and there. It isn't always this easy, but it is always a good starting point. Some of the information contained herein may be old hat to many of you. If that's the case good job keep reading and learning.

More importantly, make that information available to others. State and local organizations are always looking for knowledgeable DCs to help mentor younger more recent grads.

Where to Begin

So, you're ready to expand your knowledge. Where to begin?

The first place to look is within your own ledger. See where you are getting the most consistent denials, or for which services you are often denied. Look into the current guidelines surrounding these services.

Call the payer who is denying the service and ask them what guidelines they are using to make their determination. Review the guideline and see if you are within them. It is possible to quote another comparable reference, but it is unlikely that the person on the other end of the line will acknowledge it.

This may seem like a lot of extra work to get paid for a service that should be, or is covered. This is how things are today.

The more larger question is how do I find the time to keep track of all of this. I cannot tell you what to do or what may or may not be right for your practice. All I can do is tell you what others have done. Some offices simply hire someone to manage this aspect of the practice.

Some large offices have multiple individuals devoted to this realm of the practice. Others add this to the job requirements of their billing staff. This often works for mid-sized offices as the billing people are already deeply involved with the third party system and many have coding degrees and certification. If you are a small office, you may have to do this yourself.

This may seem daunting, but as the system becomes more and more complex it will become vital to protecting your ability to make an honest living and to render the treatment your patient needs, when they need it.

• Learn the rules.
• Study the guidelines.
• Read the current research and who wrote it.
• Read who has adopted it.

If you disagree, get involved. Write to the author and question. We must stop sitting on our proverbial hands as a profession. We need to spend more time setting policies that effect us and less time reacting to policies set by someone else. This is the only way we, as a profession, will survive and thrive.