Academic OB/GYN

In a previous post I talked about how the insurance appeals process works.  In this post I’ll talk about the things every doctor can do to maximize the chance that insurance appeals will go in their favor.  But first, a quick review.

Coverage requests get rejected when the requested service does not fit within an insurance company’s initial guidelines for approval.  This happens for a number of reasons, but usually it comes down to poor documentation or inappropriate care, or in some cases care that is appropriate but can’t be supported in the literature.  When a denial occurs, the physician or patient has several opportunities to appeal this decision.  The first appeal is about proving that your case does meet the insurance guidelines and that it was incorrectly rejected.  The second appeal is about proving that the request should be accepted outside of the coverage guidelines.  Sometimes there is another level that looks at whether the care is experimental.

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