Executive Summary

Was a stat MRI ordered with only a diagnosis of headache to support the need for the test? Expect a denial in short order.

“I tell physicians that if the procedure or test is needed immediately, the information has to support the test,” says Brandi Nash, a revenue cycle consultant at Warbird Consulting Partners in Atlanta.

Medical necessity denials are common for stat diagnostic tests. Usually, this is because the diagnosis does not support the urgency of the test.

“Without a strong diagnosis, the insurance company will toss it out before they even review it,” says Nash.

Early Discussion Needed

Some payers are applying similar rules for medical necessity as the national or local coverage determination criteria that Medicare uses. 

“Not coincidentally, many of these payers are ones who also offer Medicare Advantage plans,” says Neal McKnight, associate vice president for revenue management at Danville, PA-based Geisinger. McKnight says patient access can prevent denials in these ways:

• Integrate medical necessity rule checking with provider ordering.
• Provide scripting and training for everyone involved.
• Ensure that medical necessity rules are in compliance with payer contracts.

“Depending on your third-party contracts, a discussion early in the process may be appropriate between the provider representative — for example, a patient access representative — and the patient,” says McKnight.

This discussion would cover the fact that insurance may not cover the test or procedure. “Therefore, the patient may be asked to pay for the test,” he says.

Enlist Patient’s Help

McKnight suggests implementing a diagnosis-vs-procedure checking process at the point of scheduling or order entry. This is similar to Medicare’s Advanced Beneficiary Notice, but could be done for patients other than Medicare patients.

“A written explanation could be printed to provide the patient with details to assist in any discussion around benefits or payment expectations,” says McKnight. He says it should include:

• the diagnosis code(s), the procedure code, the reason for the potential denial, the estimated charges for the services, and the telephone number of the insurance company;
• language stating that the decision of whether to pay for services is based on the payer’s definition of medical necessity;
• a description of the intent to bill the insurance company, and/or the option for the patient to pay for the test or procedure at the time of service.

Patients also can help to intervene, by writing directly to the payer. This can sometimes prevent a denial.

“The patient can reach out to the provider to add additional diagnosis codes to justify medical necessity, or offer alternatives to the prescribed test or procedure,” adds McKnight.

Burden on Patient Access

When payers refuse to authorize a covered service, peer-to-peer discussions can sometimes override this. However, this isn’t always an option anymore.

Recently, one of the Geisinger’s Medicare Advantage payers discontinued the peer-to-peer process altogether for prior authorization requests. “The expectation is that the related denials would be formally appealed after the fact,” says McKnight.

This places the administrative burden to appeal the medical necessity denial, and meet all required response times, squarely on the shoulders of patient access.

“It is important that the revenue cycle team, including patient access, has a thorough knowledge of the payers’ medical and administrative policies, with processes set up for timely and complete appeals,” says McKnight.

Much of the communication, documentation, and justification is moving “upstream,” says McKnight. “This may involve moving the bulk of the heavy lifting to pre-service or maybe pre-billing.”

Whether a medical necessity denial is successfully overturned — or not — depends a lot on the front end.

“Patient access can ensure that the order itself is complete, that the documentation is available and that the communication with case management is transparent,” says McKnight. 

SOURCES

• Neal McKnight, Associate Vice President, Revenue Management, Geisinger, Danville, PA. Phone: (570) 271-6084. Email: nlmcknight@geisinger.edu.
• Brandi Nash, Patient Access Specialist, Warbird Consulting, Atlanta, GA. Phone: (406) 672-3909. Email: Bnash@warbirdcp.com.