Rebuttal affidavits are prepared to contradict a health insurance denial, and need to be carefully drafted. For an effective rebuttal, you need to understand the reason(s) for the claim denial. This in turn requires a comprehensive medical record review that will provide the supporting medical evidence. It is only with this evidence you can refute the denial decision made by the insurer. Given the importance of medical evidence, it is best that you get the record review performed by a professional provider of medical review solutions.
Rebuttals may have to be prepared in connection with claim denials for the following.
- Allied health treatments such as physiotherapy, acupuncture, and occupational therapy
- Investigations such as radiology, pathology, CT scans, certain lab tests
- DMR or Durable Medical Equipment that supports TENS units, Braces, and other products
- Corrective surgeries, and surgical interventions such as implants
What are the most common reasons for claim denial?
- Services that are not medically necessary: This type of denial occurs when the insurer thinks that the claimant really doesn’t need the requested service. Or, the claimant does need the service, but has failed to convince the insurer regarding the necessity. More documentation or information is required from the claimant’s healthcare provider.
- A less expensive alternative may be available: In this case, the requested service may be approved if the claimant tries the less expensive option available and it doesn’t work.
- Mix-ups and errors: When there is an error in the claimant’s name or the medical billing code, the claim may be denied.
- Non-covered service: The claim is denied because the requested service isn’t covered by the insurance plan. Claims for treatments not approved by the FDA such as some cosmetic surgery or treatments may be denied. If the claimant has purchased a plan that isn’t regulated by the ACA (Affordable Care Act) rules such as a fixed indemnity plan or a short-term health plan, it wouldn’t cover services such as mental health care, prescription drugs, maternity care and so on that a health plan usually may cover.
- Insufficient details: Denials based on this reason occur when the information provided with the claim or pre-authorization request is not sufficient. For instance, the service requested is an MRI of the lungs, but no information regarding the problem with the lungs has been provided by the treating physician(s).
- Out-of-network provider: Coverage may be available only for services provided by healthcare facilities and providers that are part of the claimant’s plan’s provider network. If prior authorization is sought for a service performed by an out-of-work network provider, the insurer may approve the service if the claimant chooses a different healthcare provider who is within the plan’s network. The insurer may approve the service if the claimant can establish that the chosen provider is the only one capable of providing the particular service.
- Investigative or experimental treatment: These are not typically covered by health insurers. However, if the medical provider can include details such as the following in the rebuttal, the requested service may be covered.
- The treatment is medically necessary and considered standard treatment by the healthcare community
- It is the only treatment that is effective
- It is a service that the health plan had earlier covered for patients with the same medical condition
- The procedure is less expensive than standard treatment
- The health plan’s rules were not followed: This happens when the claimant fails to follow rules such as pre-authorization requirement for certain services.
- In-home medical care: Most insurers deny in-home care. However, if the claimant can prove that it is a less expensive option and also meets the medical needs of the claimant, the health insurer may approve the same. Importantly, the insurer would want the in-home treatment plan attached along with the rebuttal.
Rebuttals have a significant role to play in medical litigation such as the above-mentioned examples. Therefore, they have to be well-drafted and presented.
The following facts should be clearly mentioned:
- Name of the patient, health plan claim number, and the denied claim period
- Reason for claim denial
- Chronology of medical events
- Highlighted evidence that supports the accuracy of the information provided in the claim
- Provide clear explanation regarding why the claim is genuine and should be approved
- Contain evidence that supports the medical necessity of the treatment and medications prescribed.
Though there are a number of reasons for claim denials and prior and strong evidence supporting the claim, a denial decision could be reversed. Claimants and injury attorneys can utilize medical review solutions that include rebuttal affidavit preparation. This will ensure that the rebuttal is accurate, to-the-point, concise and without grammatical errors. The explanations will be reasonable, convincing and effective so that the health insurer would understand that the claim is legitimate and the service is medically necessary.
Read our infographic on What Should Rebuttal Affidavits In Medical Litigation Include? [Infographic]