Thanks to the Affordable Care Act (ACA) patients have the right to appeal decisions made by their providers and by the insurers. The appeals process contributes to continuous improvement and greater efficiencies for all healthcare.
The (Very) Basics
The extent of the appeals process depends on many factors, including state and type of coverage. Appeals may go through as many as six levels (Medicare), though the National Association of Independent Review Organizations (NAIRO) outlines three commonly held steps:
1) A first level internal appeal.
2) A second level internal appeal. (There may be one or two levels of internal appeal, depending on the plan type and design.)
3) A third level external appeal.
Medical peer-to-peer review process allows attending, treating, or ordering physicians to request a peer-to-peer review offering additional information and further discussion on their cases with a payer’s peer clinical reviewers who made the initial adverse determination. It is important to note a medical peer-to-peer review is not an appeal. An appeal is a request by the patient or their authorized representative for a payer to review and reverse the denial.
A check and balance system exists between submission and payments of claims which works to contain the level of care and the expenses of care throughout the healthcare system. As defined by NAIRO, the 1st and 2nd levels are considered internal because these self-checks examine if internal procedures, processes, and utilization limits fall within plan coverage and medical criteria.
The external review occurs when a disagreement still exists regarding coverage or payment. The role of an Independent Review Organization (IRO) during the external review process is to act as an objective arbiter and determine, based on plan language, evidence-based medicine and regulatory requirements, whether the services in question meet the criteria for coverage under the health insurance plan.
Learning From The Squeaky Wheel
The appeals process drives long-term improvement as quality review step. Unfortunately, in the short-term, each level of the appeals process drives up the expenses for the individual case. So make a good return on the investment of resources for each appeal by capturing and analyzing the appealed cases.
Appeals may uncover:
· Conflicts of Interest
· Need for specialized review expertise
· Misunderstanding of ICD-10 codes
· Implementation gaps for new levels of coverage
· Paperwork quality control improvements