Why Rebuttals Are Vital to Challenge Insurance Claim Denials

by | Published on Mar 12, 2021 | Medical Record Review

Rebuttal preparation is one of the solutions a medical record review company provides that attorneys and physicians dealing with claim denials find very useful. Health insurance companies often deny medical claims submitted by healthcare providers saying that the medical services are not necessary. These denials are a major concern for patients who are seriously or chronically ill. The health insurer could deny medications, surgeries, investigations and physiotherapies. So, rebutting these denials becomes necessary and can be quite challenging as well. A rebuttal gives the provider the opportunity and medium to express why the services are vital to the patient. It is important that the rebuttal contains clear evidence to prove medical necessity, and refutes the denial. When preparing the rebuttal, you should have a clear understanding of the reasons for claim denial. Rebuttal preparation can be made more efficient and successful with the dedicated support of a medical chart review company.

Let Us Look at the Common Reasons for Insurance Claim Denial

  • Medical billing errors, or incomplete or missing information in the claim.
  • The claimant may have exceeded the coverage limits of the health plan.
  • The procedure or service may not be considered medically necessary; or the plan may not cover what the patient is claiming.
  • The therapy or drug is off-formulary and not part of the claimant’s health plan.
  • The claimant may have used out-of-network services; or he/she may have used the insurance out of state when his/her health plan required in-network providers.
  • Duplicate claim for the service provided. This happens when medical claims are submitted more than once for the same service provided for the same beneficiary on the same date by the same provider, and in a single encounter.
  • The service is already included under other services/procedures.
  • The services are not covered by the payer.

The Medical Necessity Conundrum

Medical necessity is one of the major reasons for claim denials, and different insurers may have different definitions for medical necessity. Typically, any reasonable procedure, service, or treatment that will reduce the impact of a health condition or illness, prevent the onset of a condition, or help a person regain full functional capacity is considered medically necessary. Medicare plans define medical necessity based on national and local coverage determination standards and are required to provide coverage in keeping with state and federal laws and rules. Private payers without Medicare plans may have their own definition and criteria for medical necessity. A doctor may sometimes recommend some treatment to get a patient back to full health, and the drugs used may be more expensive, or the procedure/treatment more time-consuming. Since the health and welfare of the patient are most important, treating doctors expect the procedure or treatment to be reimbursed. If the payer denies coverage, there comes the need for rebuttals and appeals.

What Are the Services That Often Need Rebuttals?

  • Investigations such as pathology, radiology, CT scans, lab tests, MRI scans etc.
  • Injectables/anesthesia
  • Allied Health Treatments that include occupational therapy, acupuncture, and physiotherapy.
  • Chiropractic care, physical therapy
  • DME or durable medical equipment that supports TENS units, Braces, etc.; surgical consults
  • Functional restoration programs or FRP
  • Medications
  • Spinal cord stimulators, spinal injections, etc.
  • Surgical interventions that include corrective, implant, and other surgical procedures.

Necessary Features of a Good Rebuttal

Given the significance of rebuttals, there are some essential features expected of an effective rebuttal document. It should contain the patient’s name, health plan claim number, and the denied claim period. It should be concise and focused without undue digressions, and clearly specify the reason why the claim was denied. The course of medical events should be clearly recorded. The rebuttal should be error-free and written in good English. The explanations given should be genuine and legally valid. A good rebuttal would display solid research and excellent knowledge of the particular claim. By emphasizing strong evidence that endorses the accuracy of the information provided in the claim, it should explain why the claim is genuine and must be granted. Above all, the rebuttal report should contain clear evidence that supports the medical necessity of all the treatments and prescribed medications.

The Advantages of a Well-drafted Rebuttal

  • It would definitively state that the procedure/service/treatment is something the patient deserves and medically necessary.
  • It saves time and money
  • Helps to attest the care and treatment
  • Support the ongoing course of treatment
  • Helps to effectively rebut IMEs (Independent Medical Examinations) and peer reviews

Rebutting a health insurance company’s claim denial can be challenging and an experienced legal team can provide the required efficient support. Assisting the legal team is usually a medical claim review company that provides professional rebuttal drafting solutions. The advantage of having such a partnering company is that they would review all the medical records and bills to have a comprehensive understanding of the case and the basis of denial. Rebuttal preparation being one of their core jobs, preparing the same with all the required specificities is easy for them. Besides reviewing and listing the missing elements in the case, they would also bring to focus the medical necessity of the services provided in an apt and convincing way.

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