Medical Claim Denials and Rebuttals – an Overview

by | Feb 24, 2020 | Legal Rebuttals

Health plans often deny claims to patients quoting lack of medical necessity as the reason for the denial. These denials are quite distressing for seriously ill patients as well as the healthcare providers involved in providing the treatment. To contest a denied claim, you need to prepare rebuttals and appeal letters and this requires considerable time, effort, and persistence. The rebuttal should contain evidence that can refute the assertion of denial made by the insurer. If the rebuttal is to be effective, you must clearly understand why the claim was rejected. This requires a comprehensive medical record review of the medical chart within the denied claim period. This is best done with professional assistance by a provider of medical review solutions.

Typical Claim Denials

Medical claims usually denied and for which rebuttals need to be prepared include:

  • Durable medical equipment or DME
  • Associated health treatments such as physiotherapy, occupational therapy, acupuncture and so on
  • Medical investigations including MRIs, CT scans, Labs, radiology tests etc.
  • Anesthesia/injectable
  • Surgical interventions such as implants, corrective surgeries

Reasons for Claim Denials

Let us consider the common reasons for medical claim denials and what the rebuttal should contain:

  • Medically unnecessary: In such cases, the rebuttal should make it clear why the medical provider thinks the particular treatment or medical service provided is medically necessary. Medical records, the recommendation of why the patient should have the service, and literature supporting such medical services for the particular condition should be attached along with the rebuttal.
  • Out-of-network provider: If the healthcare provider is out-of-network, you need to show that the health plan did not have access to a provider with the particular specialty in-network. Or you can mention the long wait time involved waiting for an in-network provider.
  • Experimental: Typically, experimental treatments are not covered. However, it may be covered if the medical provider can include details such as the following in the rebuttal or appeal.
    • It is the only treatment that is effective
    • It is medically necessary and regarded as standard treatment by the healthcare community
    • It is a procedure that the health plan had earlier covered for patients with the same medical condition
    • The procedure is less expensive than standard treatment
  • Health plan cancelled following failure to make payment: In this case, the rebuttal should clarify why the payment was not made. It could be a payroll error, or the patient had forgotten to notify the insurer of a new bank account made. A request can be made to the payor to make a one-time exception and restore the policy.
  • Healthcare setting, whether in-home or hospital: In-home care is often denied, but it may be covered if you can convince the insurer that it is a less expensive option and will meet the medical needs of the patient. An in-home treatment plan approved by the medical service provider must be attached along with the rebuttal.

It’s Important to Ensure a Well-drafted Rebuttal

A good rebuttal report would contain the patient’s name, health plan claim number, and the denied claim period. It should clearly state the reason why the claim was denied, and concisely record the course of medical events. The rebuttal should highlight strong evidence that substantiates the accuracy of the information provided in the claim. It should explain why the claim is genuine and should be granted. It should also contain evidence that supports the medical necessity of the prescribed medications and treatment.

As mentioned at the outset, to ensure a perfect rebuttal it is best to obtain the expert assistance of a chart review company. This would ensure that the rebuttal is concise, to the point and accurate without language errors. All explanations provided would be reasonable, valid and convincing and supported with the necessary research material. The rebuttal would be well-written and establish that the patient received the warranted medically necessary treatment.

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