Editor’s Note: Have Claim Denials Gone to the Dogs?
By Lee DeOrio
For The Record
Vol. 33 No. 5 P. 4
Whether it’s at the rim, before the big school dance, or when applying for a coveted position, no one likes to be rejected. Now think of the multitudes of claims being denied each day. Most health care facilities realize it comes with the territory, but there’s still bound to be plenty of frustration.
The common refrain may be, “Who is making these decisions, and why are they hellbent on making my life miserable?”
I recently received a note from a reader who wanted to know whether the people making decisions on claims were competent and licensed to make these rulings: “Board-certified physicians are examined by their peers, whereas in the claims denial practice no such practice is observed, thus can a veterinarian make a medical necessity judgment pertaining to a human clinical situation?”
It is important to understand that denial of payment is not necessarily a question of care that was provided. There are many reasons for claim denials that a nonclinician would be qualified to make such a determination. For example, a pharmacist could appropriately deny a claim for a mismatch between charges billed and documented dose or type of medication provided, or even for medical necessity of the type of treatment.
For health care organizations that deal with Medicaid, Medicare, and large commercial payers, denial policies are typically well documented, and a physician determines whether to agree with the denial or render the decision that a particular patient does not fit into the cookie-cutter expectations of the criteria set. That MD might well be a semiretired obstetrician who is signing off on medical necessity denials for complex geriatric or neurology or trauma treatment, which can certainly be problematic.
“If an organization is [Utilization Review Accreditation Commission]-accredited, a length of stay or medical necessity denial is always done by a physician, with an opportunity for immediate specialty-matched appeal review,” says Tracey Goessel, a principal at FairCode. “They review against published standard-of-care guidelines. I think the medical loss ratio in private insurers is far too high, but I cannot accuse them of using veterinarians. However, if the denial is made on a diagnosis-related group assignment basis, it is a fair bet that payers are not using physicians trained in the rules and regulations of medical coding. Those are as scarce as hen’s teeth.”
The professional competence of the denier may or may not be an issue. Policies that govern what gets denied, who can deny it, what can be appealed, and how that has to be done are dictated by the contract between the provider and the third-party payer. Therefore, it’s crucial, when possible, to have physicians and other affected care providers actively engaged in contract negotiations with payers. It’s easier to keep denial craziness from going into the contract than it is to try to get out of a denial straitjacket once you’re trapped in it.
Has a veterinarian ever denied a claim for human care? Cynics say they wouldn’t put it past some smaller third-party payers. Now there’s something to chew on.