Last Updated on Monday, 16 April 2012 20:53
When a healthcare plan denies a patient coverage for a treatment, procedure or service, doctors and their clinical care staff are in an ideal position to help the patient effectively appeal the denial. A new tip sheet from NAIRO shows doctors and their staff how they can help.
“Providers and their staff can dramatically improve their patients’ overall success in appealing denied claims,” said Terri Giorgio, president of NAIRO, the National Association of Independent Review Organizations.
The United States Department of Labor and in most states, the state insurance department authorizes an appeals process that grants patients the right to seek internal appeals, as well as external appeals conducted by an independent review organization (IRO).
“Our current legislation does not make it easy to understand how to file an appeal when a health plan denies a treatment, procedure or service,” Giorgio said. “Many healthcare consumers are confused about internal and external appeal rights extended to them by the healthcare legislation. Because doctors and their clinical staff understand the medical rationale for a procedure, they are in a much better position to clearly document the reasons for the internal or external appeal and help their patients understand the plan’s appeal process.”
Tip Sheet for Providers
To help providers, NAIRO recently published a tip sheet for providers, doctors and patient advocates outlining the appeal process for patient claims denied by health plans. “Do You Know How to Assist in Recovering Costs for Your Patients’ Claim Denials?” is available on the NAIRO website. The tip sheet provides doctors and patient advocates with information about appeals and includes a simple questionnaire that providers can help to fill out for their patient. The form is available on the NAIRO website.
Last year, NAIRO also published a question and answer primer to help healthcare consumers with appeals. NAIRO’s “Know your Healthcare Appeal Rights: A Q&A on the Health Insurance Appeals Process for Consumers” makes it easier for consumers to understand how to correctly file an internal or external healthcare appeal.
The tip sheet “Do You Know How to Assist in Recovering Costs for Your Patients’ Claim Denials?” is available on the NAIRO website. The sheet also provides doctors, patient advocates and other clinical staff with basic information about internal and external appeals. In addition, the sheet contains a questionnaire they can use to help gather appeal information and answers essential questions about the appeal process. Both can be found at http://nairo.org/_pdf/claim_appeal_form.pdf.
Consumers and others interested in the healthcare appeal process may also want to download “Know Your Healthcare Appeal Rights: A Q&A on the Health Insurance Appeals Process for Consumers” at http://nairo.org/_pdf/uploads/consumerappealsfaqnairo.pdf.
NAIRO works to promote the value and integrity of the independent medical review process. Its 28 member organizations embrace an independent, evidence-based approach to medical review for resolving coverage disputes between enrollees and their health plans. This article originally published by NAIRO. To view the article, visit www.nairo.org.