Healthcare Services

Healthcare Appeals: A View from the Bench (Part I)

Healthcare Appeals: A View from the Bench (Part I)

By Keith Saunders

Every appeal represents a failure.

If this seems like a harsh and jaded view of healthcare reimbursement, consider that I have served as an Administrative Law Judge and Hearing Officer for both the Medicare and Medicaid programs for more than 20 years. I am well versed in the many ways that the administration of benefits can go wrong, creating challenges for both payers and patients.

There are two major ways to fail. The first type of failure occurs on the part of the person or entity submitting the appeal.  These issues include:

  • Failure to verify that an individual is covered under their reimbursement program.
  • Failure to verify that the service or supply being furnished is a covered benefit.
  • Failure to understand the coverage and payment guidelines for a particular service or supply. This is usually coupled with the failure to maintain current knowledge regarding policy and regulatory changes.
  • Failure to ensure that the documentation in the patient’s medical record supports coverage under the coverage and payment guidelines.
  • Failure to document the medical necessity for an item or service when seeking individual consideration by the payer.

The second type of failure occurs on the part of the payer who is adjudicating the appeal. Contrary to popular myth, payers do make mistakes, such as:

  • Failure to apply the correct coverage and payment guidelines to a case.
  • Failure to review the record sufficiently to extract relevant data to correctly apply the coverage and payment guidelines.
  • Failure to understand the medical evidence within the record.
  • Failure to review collateral evidence within the record to make a determination.
  • Failure to adequately convey program requirements through supplier outreach and educational efforts.

So what is an Appellant or payer to do? We will be addressing the answer in subsequent blogs over the course of the next few weeks. Check back next week for our tips on how to avoid these failures in the first place.