The Wisdom of Yogi Berra in Medical Benefit Appeals

Posted on October 31, 2018 I Written By

The following is a guest blog post by Keith J. Saunders, Esq., Founder & CEO of FHAS.

“This hearing will now come to order.  For the record, today’s date is…and the following parties are present…”

I have repeated this sentence thousands of times over the past twenty three years while serving as a hearing officer for the Federal Medicare program and as an Administrative Law Judge (ALJ) for the Commonwealth of Pennsylvania Medicaid program.  Serving as an adjudicating official for medical benefit appeals can provide one with a unique perspective on human nature and the shortcomings of the medical appeals process. 

In this post, I would like to share three takeaways from my experience in order to assist you in being a successful participant in the appeals process, whether you participate from the side of the payor or appellant.

Know the medical facts.

My first piece of advice is inspired by a quote from the great New York Yankees baseball player and manager Yogi Berra: “You can observe a lot just by watching”.  Most participants in medical benefit appeals fail to perform the requisite watching.

If you are going to successfully defend or pursue your appeal, you must know the medical facts of the case. This might seem obvious, however you would be shocked to learn how many times a claim denial is appealed and it is very apparent that the parties don’t know or understand the condition of the patient, underlying the facts of their case. For medical provider appellants who are part of large health systems, the need to survey all records within your system pertaining to the subject of the appeal is critical.

For third party payers it is likewise critical to ensure that you possess a complete understanding of the condition of the patient.  I once presided over a hearing where the health insurer was challenging the necessity for the patient to have a wheelchair.  They indicated that the medical information submitted with the claims failed to indicate that the patient could not walk.   If they had performed a survey of the medical records contained within the file they would have ascertained that the patient was a bilateral AKA. For those of you who do not frequently traverse through medical records, this acronym stands for bilateral above the knee amputee; this patient had no legs.

Understand why the claim was denied.

Turning again to Yogi Berra for my second piece of advice: “You’ve got to be very careful if you don’t know where you are going because you might not get there.” In order to be an effective advocate for your position, you must thoroughly understand why a claim for reimbursement has been denied by the third party payor.  One of the most frequent bases advanced for denials in both the Medicare and Medicaid programs is the blanket catchall basis of, “a lack of medical necessity”.  This basis is utilized to deny submitted claims which lack a valid physician’s signature on the order, claims which fail to meet specific medical necessity criteria, or even claims that were not submitted in a timely manner.

As an appellant, you must possess a thorough understanding regarding what has transpired from the reimbursement standpoint, end of story.  If you are an appellant, please read the basis for the claim denial being put forth by the third party payer. To take my Yogi quote further, it is impossible for you as an advocate to get where you want to go, that is, get paid, if you do not know why the claim has been denied. When you as an appellant receive a denial notice, whether it is an explanation of benefits or a remittance advice, review the basis for denial.  If it indicates that critical medical necessity evidence is missing, review your records to find it.

Arguments that the medical policy is foolish or that the payor doesn’t understand what the patient needs may make you feel better for having given the adjudicator a piece of your mind, but are ultimately ineffective. I once had an appellant argue to me that requiring a physician’s order was a foolish requirement for an orthotic device.  When I asked the gentleman making that arguments how a payor was to ascertain if an item was medically necessary, he indicated that they should just ask him, the vendor.  Needless to say that was not an effective argument.

If you have received a blanket denial, such as a lack of medical necessity, please reach out to the third party payor to ascertain what exactly is missing or unclear.  Once you have determined what the problem is, you are then in a position to solve it.

Know the coverage and payment guidelines.

My final recommendation is that you acquire an in-depth knowledge of the coverage and payment guidelines or medical policies which govern the items or services for which you are seeking payment.  As a hearing officer or ALJ, I would find myself frequently asking appellants or payor representatives to furnish the basis within the policies for the denial of items.  More often than not on both sides of a case, neither party could articulate why an item should or should not have been paid.

I suppose in those situations they turned to another quote from Yogi: “If you ask me a question I don’t know, I’m not going to answer it.” Today there is no reason for any party to be unaware or unknowledgeable regarding medical policies or coverage and payment guidelines. All commercial health insurers and government programs, such as Medicare and Medicaid, publish their policies online.  Knowledge of the rules is one of the cornerstones to being a strong advocate for your position. From the provider standpoint, it is one of the critical components needed in order to have an item covered by a payor.

My advice may seem rather basic, but years of experience have shown me that it is a failure to address the fundamentals which causes most claims to be denied. In summary: 1. Know your patient and the medical records surrounding a claim; 2. Know the facts surrounding why reimbursement has been denied; 3. Know the rules which govern payment criteria for your claim.

If you pay attention to the foregoing you will be a much stronger advocate for your position and will likewise achieve and maintain a higher success rate in your appeals. In medical benefit appeals, as in baseball, “It ain’t over until it’s over.”

About Keith J. Saunders, Esq.
Keith J. Saunders, Esq. is the Founder & CEO of FHAS, a leading provider of medical review analytics and support services to government and commercial sectors. Weaving together over 30 years of experience working on behalf of health plans, providers, and government agencies, Mr. Saunders furnishes his clients with valued-based solutions that minimize administrative waste, maximize return on investment, and yield holistic results for all stakeholders. A former General Counsel to Blue Cross Blue Shield Plans, Mr. Saunders was an Air Force Judge Advocate proudly serving in Operation Desert Shield/Desert Storm. Mr. Saunders attained his Juris Doctorate from Duquesne University and is a long-time member of the American Health Lawyers Association (AHLA).

About FHAS
FHAS, a URAC accredited IRO and ISO 9001 certified company, is one of the largest independent providers of “healthcare as a service” (HAAS) for government and commercial clients with a particular focus on adjudication services and medical claims’ review services. In 1996, FHAS began furnishing Medicare Fair Hearing Services to Durable Medical Equipment (DME) Administrative contractors located throughout the United States. Since that time, FHAS has expanded its scope of appeals services to include complex medical reviews for the following: Medicare Parts A, B, PDRC Appeals, and DME Appeals, internal and external health plan appeals, and the entire Pennsylvania Medicaid fair hearing process. FHAS utilizes a network of board certified physicians, legal professionals, and other healthcare professionals with diverse specialties, who have the expertise to render decisions for external review requests. In addition to professional services, FHAS provides enterprise-grade software solutions to healthcare and insurance industries. Their newest product Cogno-Solve is a comprehensive, RPA software platform that automates claims and appeals decision-making functions.