Navigating the Patient Appeals Process
When faced with a health plan denial, work with your patient to appeal the decision.
Fam Pract Manag. 2000 Oct;7(9):43-46.
Nothing is certain in life except death and taxes.” As a physician, you would probably add “denials” to this list. According to a 1999 survey by the Henry J. Kaiser Family Foundation, nearly nine out of 10 physicians had treatments they ordered denied by a health plan over two years.1
Because you're a good patient advocate, you may appeal some of these denials on behalf of your patients. And although you may feel like you're up a creek without a paddle in these situations, there are ways to navigate the appeals process without getting swamped.
As your patients' advocate, you have a responsibility to help them appeal health plan denials in some cases.
Limit your liability exposure in the appeals process by basing your appeal decisions on what's best for the patient.
Improve your chances in the appeals process by learning about the plan's requirements and your appeal options and by having an appeal strategy.
Why should you appeal?
You can think of plenty of excuses for not appealing a health plan denial — the pressures of financial incentives, the uncertainties you face in the marketplace (i.e., “Will I be deselected if I appeal?”) and the paperwork and time demands. So, when faced with another denial, it's easy to say, “So what? It's not my problem. Let the patient work it out.”
That's the easy answer, but it's not always the best one because the vast majority of the time, the patient won't work it out. A recent survey conducted by the Kaiser Family Foundation2 found that only 6 percent of people reporting a conflict with their health plan filed a formal appeal.
The fact is that you are an advocate for your patient, and as such, there are times when you have a moral, legal and fiduciary responsibility to recommend appropriate care for the patient. If you choose not to appeal — perhaps because you anticipate another denial — you may be failing to fulfill your professional duty. Delaying or failing to appeal an adverse decision or delaying care because of the appeals process makes you potentially liable for any adverse effects the patient may experience. (See “The legal standard.”)
Since your expertise is needed to support your patients' claims that services are medically necessary, advocating for your patients is critical to helping them achieve the benefits of their appeal rights. Notice that we are talking about patients' appeal rights. Although you may have a responsibility to appeal, you should enlist patients in the process as much as possible (by having them obtain plan information, exercise their own appeal options, etc.), so that you minimize the burden on you and advocate for themselves; don't just advocate for them.
To limit your liability exposure in the appeals process, always keep in mind what's best for the patient and act accordingly (even at the risk of nonpayment), pursue all available appeals and document that you submitted appeal requests in a timely fashion.
The legal standard
Several court decisions, such as Wickline v State of California, 192 Cal App 3d 1630, 239 Cal Rptr 810 (2d Dist 1986), unequivocally hold physicians responsible for doing everything possible to see that their patients receive appropriate care, regardless of a health plan's decisions and in spite of the fear of annoying plan representatives or being deselected. In particular, Wickline clarified that a physician who complies without protest with limitations on treatment imposed by a third-party payer when the physician's medical judgment dictates otherwise cannot avoid his or her ultimate responsibility for the patient's care. The legal standard is that the doctor has to take care of the patient, period.
Ideally, you should try to avoid the appeals process by avoiding denials in the first place. Some denials are a consequence of actions within the control of you and your staff. For example, health plans often deny or return preauthorization requests because of missing data. You can avoid this by ensuring that your preauthorization requests include accurate and complete patient demographics as well as the proper diagnosis and procedure codes. Good documentation can also help you to avoid denials.
Have someone on your staff analyze the reasons for the denials you receive, identify those within your control and make changes that will enable you to avoid the problems up front. Keep in mind that the necessary changes may involve anything from rethinking a simple office procedure to renegotiating the terms of your contract with a health plan. Think of this as preventive medicine for the ills of the appeals process.
Improving your chances
If you do have to appeal, your chances for success may be better than you think. According to the 1999 Kaiser Family Foundation study, 42 percent of physicians said that their most recent treatment denial was ultimately resolved in the patient's favor.1 Here are some suggestions for tilting the odds in your patients' favor.
Know when to appeal. Not every denial demands an appeal. For example, when a patient requests something inappropriate (such as out-of-plan care when quality, in-plan care is available or when a patient's benefits have been exceeded) it is reasonable and defensible to accept the denial without question. Knowing when to appeal, or how to pick your battles, is important because you have neither the time nor the resources needed to appeal every denial that comes your way.
Know the health plan's requirements. According to a study by the U.S. General Accounting Office, most patients do not read the handbooks their health plans provide, so they're unfamiliar with the plans' requirements.3 Consequently, many appeals stem from ignorance.
Ask the patient to assist you in getting his or her plan information. This not only saves you time, but it also lets the patient know you are acting as his or her advocate. If you have to get the plan information yourself, contact the human resources department at the patient's or the insured's employer. Then be sure to review any relevant plan information before you initiate your appeal.
Know your appeal options. The appeals process will vary among and even within health plans. Still, some elements are common, and you should be aware of them.
Most appeals processes include explicit time frames for responding to appeals. Knowing those time frames helps you and your patient protect your appeal rights through timely action. Most appeals processes also include an expedited appeal option that you may be able to take advantage of under certain circumstances.
The internal appeals process in most plans has two levels, so if the first appeal is denied, you should be prepared to discuss further appeal options with the patient or take advantage of them yourself. If your internal appeals are denied, or if the plan's internal appeals process is unacceptable or nonexistent, you or your patient may also be able to pursue appropriate redress outside the plan. In fact, in most states, external review is the third stage of the appeals process. It can take on three different forms: arbitration, a grievance procedure or legal action. Before you pursue an appeal outside of a plan's appeals process, determine who has jurisdiction. Usually, it will be the state's commissioner of insurance or Department of Health or the federal courts.
For specific information about a particular plan's appeals process, consult the plan's handbook. If you're unable to find this information in the handbook, the Division of Insurance, or its equivalent in each state, should be able to persuade the plan to provide it. There are also many external influences on any plan's appeals process, so be sure to review any state or federal regulations about appeals processes. (See “External influences on the appeals process.”)
External influences on the appeals process
No health plan appeals process operates in a vacuum; a variety of influences affect it. Here are some you should be aware of:
For federal insurance programs, all executive agencies are required to implement grievance and appeal procedures recommended by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry (www.hcqualitycommission.gov).
Managed care plans that contract with Medicare must follow mandated grievance and appeal procedures as part of their Medicare contracts (www.medicare.gov).
If passed, the “Patients' Bill of Rights,” pending in Congress, will include guidelines about the appeals process.
Many states require that a health care professional with appropriate expertise participate in the appeals process, and some states explicitly limit the authority of nonphysicians to deny claims.
States have also adopted an array of policies to promote the physician's role in informing patients and assisting them in the appeals process. Laws in some states specify a role for physicians, recognizing that they may appeal a claim on behalf of a patient.
Many states protect a physician's right to advocate for medically appropriate care by prohibiting plans from disciplining a provider who advocates for such care and by defining advocacy broadly enough to include the appeal of a plan's denial of treatment.
Some states have consumer groups available to assist patients with appeals.
The National Committee for Quality Assurance's (NCQA) current standards for accreditation of managed care organizations include a requirement that physicians review any denial of care and that health plans provide members with the right to independent external appeals of denied care (www.ncqa.org).
Know your strategy. A strategy for successfully negotiating an appeal is to approach a denial as a customer-service problem — one in which the customer of a health plan (the patient) is dissatisfied with the plan's services. If you can convince the health plan to view the appeal as a chance to better serve the customer, you may improve your chances of achieving a satisfactory outcome. Customers who change plans rather than appeal denials are among the biggest threats to a health plan's viability.
As part of your strategy, consider requesting a face-to-face appeal hearing. Most plans' appeals processes allow the patient to attend at least one appeal hearing. It's much harder for the plan to say “no” to your face than it is by letter or over the phone.
The next best thing is direct phone contact with a decision maker at the plan (while uncommon, this is possible in some cases). Speaking with the medical director — a fellow physician — is often the most effective method. If you can't reach the medical director, try to reach someone at a supervisory level.
Tips for appealing denials
The next time you're faced with a health plan denial, you may choose to help your patient appeal the decision. Here are a few tips to help you navigate the appeals process:
Know when to pick your battles. Not every denial demands an appeal.
Review any relevant health plan information before you appeal.
Find out how many levels of appeal are available to you. Usually, there are two internal levels and a third external level.
Be aware of any state or federal regulations about the appeals process.
Handle appeals for your patient in a timely fashion, and document that you've done so.
Approach the appeal as a customer-service problem for the health plan.
Request a face-to-face appeal hearing or direct phone contact with a decision maker at the plan.
Always base your appeal decisions on what's best for the patient.
Navigating the process
Like death and taxes, health plan denials are inevitable for you and your patients. Together, you can successfully appeal denials if you know the plans' requirements and your appeal options. As your patients' advocate, you owe it to them to grab a paddle and help them navigate their way through the appeals process.
Kent Moore is the AAFP's manager for health care finance and delivery systems and is a contributing editor to Family Practice Management.
1. Kaiser Family Foundation and Harvard University School of Public Health. Survey of Physicians and Nurses. Menlo Park, Calif: Henry J. Kaiser Family Foundation; July 1999.
2. Kaiser Family Foundation. National Survey on Consumer Experiences with Health Plans. Menlo Park, Calif: Henry J. Kaiser Family Foundation. June 2000.
3. US General Accounting Office. HMO Complaints and Appeals: Plans' Systems Have Most Key Elements, but Consumer Concerns Remain. Washington, DC: US General Accounting Office; 1998. Publication T-HEHS-98-173.
Copyright © 2000 by the American Academy of Family Physicians.
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