Outpatient Surgery Magazine - Subscribers

Surgical Smoke Nearly Killed Me - Outpatient Surgery Magazine - February 2018

Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.

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Yes, You Can Overturn Medical Necessity Denials 3 keys to challenging — and collecting on — unfair claim denials. T hree words no surgical facility leader wants to hear: not medical- ly necessary, a derivative of med- ical 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 neces- sity. Most states have consumer protection laws that require the dis- closure 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 2 0 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • F E B R U A R U Y 2 0 1 8 Coding & Billing Tammy Tipton • ON APPEAL Do you understand your legal rights and how to argue those rights effective- ly when insurers uphold medical necessity denials unfairly?

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