I just did another appeal. I didn't know anything about the patient. I didn't want or care to know anything about the patient. Why? The answer is simple, its not about the patient. its about the benefit or the claim but even if its about the claim, its still about the benefit. The appeals I do are not personal. They're business. I keep personal and I keep emotion out of it.
What I look for are the facts. I look to see who denied the benefit. I look to find the information about the benefit. I look for policies about the benefit. In this last appeal, it was about the insurance company denying the benefit saying it wasn't medically necessary for the patient to receive the medical care. I looked for their policy about the medical care. The diagnosis documented supported the medical necessity and their policy showed that the diagnosis supported the medical necessity, so I had a match. I looked and the medical care being denied was a benefit or a covered service that the insurance company was supposed to pay.
So, lets put the puzzle together:
Piece 1: the medical care was a benefit or a covered service that is payable by the insurance company.
Piece 2: The policy defined a diagnosis that supported medical necessity.
Piece 3: The medical record documented the diagnosis that supported medical necessity, which is documented in the insurance company's policy.
The insurance company had no proof to support their medical necessity denial. The proof was all on my side of the scale. I wrote the appeal pointing to the facts, the fact that supported the benefit and the fact that supported the policy which supported the payable benefit.
Again, the bottom line was this wasn't personal, it was all business. It took me about 3 hours to put together this appeal. The time was spent doing my research, gathering the proof I needed to support the overturn of the denial. You want to win, you must gather your evidence, you must gather your proof and you must put your proof into a format where nothing but the facts are presented. 1+2+3= SUCCESS
What I look for are the facts. I look to see who denied the benefit. I look to find the information about the benefit. I look for policies about the benefit. In this last appeal, it was about the insurance company denying the benefit saying it wasn't medically necessary for the patient to receive the medical care. I looked for their policy about the medical care. The diagnosis documented supported the medical necessity and their policy showed that the diagnosis supported the medical necessity, so I had a match. I looked and the medical care being denied was a benefit or a covered service that the insurance company was supposed to pay.
So, lets put the puzzle together:
Piece 1: the medical care was a benefit or a covered service that is payable by the insurance company.
Piece 2: The policy defined a diagnosis that supported medical necessity.
Piece 3: The medical record documented the diagnosis that supported medical necessity, which is documented in the insurance company's policy.
The insurance company had no proof to support their medical necessity denial. The proof was all on my side of the scale. I wrote the appeal pointing to the facts, the fact that supported the benefit and the fact that supported the policy which supported the payable benefit.
Again, the bottom line was this wasn't personal, it was all business. It took me about 3 hours to put together this appeal. The time was spent doing my research, gathering the proof I needed to support the overturn of the denial. You want to win, you must gather your evidence, you must gather your proof and you must put your proof into a format where nothing but the facts are presented. 1+2+3= SUCCESS
