Wednesday, October 8, 2014

Patient Advocacy: Healthcare on your Side

Patient Advocacy: Healthcare on your side

   by Martine G. Brousse
Healthcare Specialist, Patient Advocate, Certified Mediator

Medical Necessity:

  Filing Successful Appeals*

"Medical necessity", used so often in denials of claims or athorizations takes on diverse meanings, based on who claims it.

Eventually the final word rests with your insurance, its guidelines, the terms of your health policy and the documentation supporting your claim.

Here are some tips to help you conquer those hard-to-win appeals.

1. Standard medical practice appeal

It is imperative that your physician) must show that the normal, well established standard of care has been followed. In a nutshell, you have been prescribed the gentler, cheaper, usual, most common course of treatment, and this is not working.

Let's say your prescription is brand name, but over the counter alternatives are available. You are liable for a higher or total share of cost for the brand name. Medical necessity would be justified if the OTC version or generic prescriptions had been tried over a certain amount of time, resulting in no improvements, a worsening of the condition, a serious side effect, or were counter-indicated.

When a surgical or invasive intervention is recommended, proving medical necessity requires records that demonstrate prior conservative, pharmaceutical or non-invasive therapies are not longer effective.

2. Insurance guidelines appeal

This appeal will be more difficult to win, but all hope is not lost. Because the terms of a contract are at play, the room to maneuver is tight.

Medical necessity would be established if conservative measures have been used and become ineffective to the point of causing irreparable damage to your health. Detailed explanations of the negative impact on your daily life, professional activities, and/or on your mental or emotional state if the prescribed treatment were not administered must be presented.

Say that you have intense back pain due to an old injury. Your policy will not cover surgery as your condition is neither acute nor hazardous to your life. It will cover pain management modalities, physical therapy and supplies such as a brace.
Exposing potential risks (addiction to pain pills), reduced quality of life (loss of mobility), inability to do your job (can't sit or drive) or onset of new related conditions (depression) would have a chance of success. The medical records would need to list unusual and serious circumstances justifying the prescribed approach.

3. FDA based appeal

We are now entering a world where cooperation from your physician is indispensable.
If your treatment has been denied as "off-label" (not approved by the FDA) or inappropriate for your diagnosis, you are unlikely to win an appeal unless highly technical clinical documentation is presented. Many specialized sources in the US are only available to physicians, while looking for supportive information elsewhere will test your research and linguistic skills.

If a prescribed treatment has a proven and effective off-label use abroad, in US drug trials (at least stage II) or as part of peer reviewed studies, it might be up for consideration. If literature supporting the physician's decision has been published in medical journals, can be located from reputable sources or is listed in the drug NCCN compendia (the "Bible of medications"), your insurance may be convinced to cover it.

Your physician must have the justification and be ready to hand over details, articles and research papers. His reasoning, supported by established facts and reasoning, should be extensively detailed in the medical records as it is out of established and standard guidelines. If not, ask yourself: on what medical grounds was the treatment prescribed?
This type of appeal is rarely done by patients, due to the complex nature of the evidence and the restricted access to resources.

In conclusion

Records from other physicians, demonstrated impact, detailed past treatments and their results should be on file in your chart. The industry's rule for payment is: " if it is not in the medical records, it did not happen". Every other insurance follows this reasoning. Unless a member of the medical profession noted it, or unless you have written proof, saying it means little. Old explanations of benefits would do, as would a history print out from a pharmacy. A letter from someone in the office, or unsigned by the physician holds no value.

Filing an appeal requires two things: stating exactly why a claim should be reprocessed or a denial overturned, and proving your point with as much relevant, legitimate documentation as you can get. 

* Previously seen on NerdWallet

©  [2016] Advimedpro.
©  [2016] Martine G. Brousse.
All rights reserved.

My objective is to offer you, the patient, concrete and beneficial information, useful tips, proven and efficient tools as well as trustworthy supportive advice as you deal with a system in the midst of sweeping adjustments, widespread misunderstandings and complex requirements.

AdvimedPro        (424) 999 4705 or (877) 658 9446      fax (424) 226 1330

Patient Advocacy: Healthcare on your Side

Patient Advocacy: Healthcare on your side

   by Martine G. Brousse
Healthcare Specialist, Patient Advocate, Certified Mediator


Few insurance denials are more frustrating that those issued for "lack of medical necessity". If your doctor prescribed a treatment or procedure, it must be medically necessary, right?

It depends. "Medically necessary" has different meanings. Understanding which one applies to your case determines your appeal options and chances of success.

1. Standard medical practice says

The most common definition is that "the service/procedure/treatment is reasonably expected to prevent the onset of a condition, reduce or ameliorate the effects of an illness or condition, or help an individual obtain or maintain maximum functional capacity".

From the insurance point of view, the most economical, least invasive, most efficient way of achieving the above is the preferred option.

Let's say your prescription is brand name, but over the counter or generic alternatives are available. In most cases, medical necessity for the more expensive drug would not be justified.

When a surgical or invasive intervention is recommended, medical necessity means no other pharmaceutical, more conservative or non-invasive therapies are indicated.

2. Your insurance (policy) says

Coverage of the same procedure or drug may vary from insurer to insurer. It is advisable to always confirm a service or prescription is covered under your policy to avoid costly surprises.

Restrictions are often found on procedures that have cheaper or less radical alternatives, or those deemed "elective". If the insurer can argue that the life or welfare of the patient are not in immediate danger, or that the condition can be managed via a more conservative approach, the medical necessity for more drastic measures is often rejected.

A good example is knee replacement: your physician may recommend immediate replacement surgery, but your insurer may impose physical therapy and pharmaceutical pain management until the condition turns more serious or for a certain length of time without improvement.

3. The FDA says

If it is not FDA approved for use or not indicated for your specific diagnosis ("off label"), it is not medically necessary... unless accepted exceptions apply.

The most important is the listing in the drug NCCN compendia (the "Bible of medications"). If an off-label use is published there, your insurance may accept to cover it. Though not FDA approved, it indicates that it has become an accepted use within the medical community.
4. The physician says

Based on professional experience your treating physician might prescribe a stronger prescription than the over the counter version, bypassing the standard protocol. He might also disregard a longer-term approach for a quicker but more drastic solution based on medical and other criteria. Medical records should and must explain this decision.

5. You say

As a billing manager, I have seen my share of cases where convenience and personal preferences were the basis for requesting a specific prescription or treatment.
While a young mother choosing to undergo a gentler but longer type of chemotherapy when the norm is a less costly, shorter but debilitating treatment can be justified, requests based on marketing ads, advise from friends and family members or indiscriminate internet research will not.

Medical providers might be tempted to prescribe a certain drug, or order a test or scan to please (and keep) their patient. Relying on unverified statements by the patient, they may be led to advise serious interventions when not truly indicated.

Unsupported by sound, appropriate medical records, it will be difficult to prove medical necessity in such cases.

In conclusion:

Depending on the point of view, medical necessity takes many forms. It usually follows established protocols. When your insurance issues a denial, it does so based on specific reasons, published policies, FDA guidelines or standard medical practices. Other valid explanations include a lack of medical records, insufficient justification or a missing authorization.

Until evidence is given supporting the need for an out-of-the-norm service in your specific case, expecting a change of decision might be a lost cause.

* previously published on NerdWallet

©  [2014] AdviMed.
©  [2014] Martine G. Brousse.
All rights reserved.

My objective is to offer you, the patient, concrete and beneficial information, useful tips, proven and efficient tools as well as trustworthy supportive advice as you deal 
with a system in the midst of sweeping adjustments, widespread misunderstandings 
and complex requirements. 

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"The flower of consciousness needs the mud out of which it grows." Eckhart Tolle

AdviMed        (424) 999 4705 or (877) 658 9446       fax (424) 226 1330