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.
2. Demand peer review. Peer review means that the appeal reviewer
has the same credentials as the treating provider. Sometimes, that
isn't a problem. However, access to sub-specialty peer reviewers is
one of the most important protections related to quality appeal deci-
sions. Sub-specialty peer reviewers have the expertise to initiate
meaningful dialogue with providers related to both treatment deci-
sions and applicable coverage limitations.
But peer reviewers are not always available, or available in a timely
manner, in the sub-specialty needed. Some reviews need board-certi-
fied sub-specialists. This can create time delays because it can be dif-
ficult to find sub-specialists who are available and haven't been
involved in the same case. Because of the potential shortage of sub-
specialty peer reviewers, your appeal should make very specific
demands regarding the credentials of the appeal reviewer. While the
Affordable Care Act's (ACA) external review requirements don't apply
to all coverage, this is a well-recognized protection to seek when ask-
ing for quality review.
3. Pursue all levels of appeals. Medicare and Medicaid have multiple
appeal levels. It's important to escalate appeals as higher-level appeal
F E B R U A R U Y 2 0 1 8 • O U T PA T I E N TS U R G E R Y. N E T • 2 1
Download a sample medical
necessity appeal letter at
outpatientsurgery.net/forms
