Three words no surgical facility leader wants to hear: not medically necessary, a derivative of medical necessity — the quasi-clinical term that payers have a hard time defining but won't hesitate to reach for when they want to say denied.

Of course, you can appeal an insurance claim denial based on a medical necessity decision, but when's the last time you took the time and trouble to do that? If you're like most administrators, you won't challenge a payer's decision — even when you suspect an insurer is upholding denials unfairly. Too much time. Too much effort. Well, you're right. It takes dogged determination, but medical necessity denials get overturned over and over. Here are 3 keys to collect on unfair medical necessity denials.

1. Review payer's "medical necessity" documentation. Payers are forever asking providers to provide documentation. But payers, too, must have written clinical criteria on which they base medical necessity. Most states have consumer protection laws that require the disclosure of the clinical criteria used in making treatment decisions. Regardless of your state's laws, ask insurers for clinical criteria so you can review it for relevance and accuracy. Obtaining the criteria lets you develop a better argument around why payers should make exceptions to this type of guidance. For example, after you discover which patient populations the criteria does and does not apply, you might be able to question the guidance on the basis of its suitability for complex patients and understudied patient populations.

2. Demand peer review. Peer review means that the appeal reviewer has the same credentials as the treating provider. Sometimes, that isn't a problem. However, access to sub-specialty peer reviewers is one of the most important protections related to quality appeal decisions. Sub-specialty peer reviewers have the expertise to initiate meaningful dialogue with providers related to both treatment decisions and applicable coverage limitations.

But peer reviewers are not always available, or available in a timely manner, in the sub-specialty needed. Some reviews need board-certified sub-specialists. This can create time delays because it can be difficult to find sub-specialists who are available and haven't been involved in the same case. Because of the potential shortage of sub-specialty peer reviewers, your appeal should make very specific demands regarding the credentials of the appeal reviewer. While the Affordable Care Act's (ACA) external review requirements don't apply to all coverage, this is a well-recognized protection to seek when asking for quality review.

3. Pursue all levels of appeals. Medicare and Medicaid have multiple appeal levels. It's important to escalate appeals as higher-level appeal reviews let you discuss poor quality appeal review components obtained at the lower levels of review.

Unfortunately, on the commercial coverage side (group and individual health plans), provider appeals are often limited to 1 or, at best, 2 internal appeals with a payer. However, obtaining an authorization from the patient to pursue external appeal review is often an option that lets you escalate to an external review process with independent decision makers.

In an effort to improve what was widely recognized as "ineffective appeal processes," the ACA sought to standardize healthcare insurance appeals for group and individual insurance plans and universally extend access to the gold standard: external/ independent review of denied healthcare claims. Since the ACA passage in 2010, independent review organizations have lined up medical dream-team level reviewers to meet the challenge of reviewing cases.

While the scope and role of independent review has grown significantly since passage of the ACA, few consumers — an estimated 1 in 1,000 — use the process. Getting consumers to file even an initial appeal, much less Level II and External Review requests, remains daunting.

Fortunately, the treating medical professional has the right to act on the patient's behalf when you believe an insurer is wrongfully denying access. The provider is often in the best position to pursue the process altogether — records collection, drafting and submission — and may even benefit from the dialogue regarding how plan/policy language addresses coverage questions.

To insure that the providers can participate, if willing, the ACA made clear that the patient can assign their right to pursue appeals to any other party: a willing family member, a training advocate or the medical organization that provided the treatment. Unfortunately, medical 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 medical 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 carrier's written criteria. For this reason, quality appeal review is critical to each of us. OSM