ical providers have come forward to indicate that insurers don't seem
to readily recognize their right to pursue external review on behalf of
the patient. Instead, providers pursing these requests for external
review say the requests often get lost, go answered or go through a
lengthy preapproval process before being referred to external review.
Quality care and patient advocacy
Besides leaving money on the table, uncontested medical necessity
denials result in a subtle shift in treatment availability to the next
patient. Remem-ber, insurance carriers aim to consistently apply med-
ical necessity limitations. Effective medical necessity appeals, on the
other hand, bring to the carrier's attention necessary variations in
care, emerging efficacy issues and situations that reveal flaws in the
day-to-day clinical
application of the car-
rier's written criteria.
For this reason, quali-
ty appeal review is
critical to each of us.
OSM
Ms. Tipton
(t.tipton@appealsolu-
tions.com) is the presi-
dent of Appeal Solutions
(appealsolutions.com)
in Oklahoma City, Okla.
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 3
