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?
