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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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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

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