Corporate Compliance

Understand when an appeal is appropriate

Compliance Monitor, December 28, 2005

Knowing when and when not to appeal is the first step in the denials-management process. Following are two cases in which an appeal is appropriate:

  • No procedure precertification. For example, a radiologist has a precertification for an abdominal CT and orders a second CT of the chest after finding an abnormality in the patient's abdomen, and the payer denies the second, nonprecertified CT scan. "It [is] better for the patient and cheaper for the payer to have both procedures done while the patient [is] still in the scanner," Rinker says.
  • Lack of medical necessity. For example, an ED patient with chronic pain usually treated by his or her primary physician experiences a sharp increase in pain, spike in temperature, or other condition. It's the middle of the night or the weekend and the patient's PCP's office is closed, so he or she goes to the ED. The payer denies the claim.

    This tip is an excerpt from Strategies for Health Care Compliance.

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