15 Tips for More Successful UR and Appeals

by Mary Graham

[Winter 1996; Vol. 23 No. 4]

Ms. Graham is Director of APA’s Office of Economic Affairs and Practice Management and this article is from the September/October 1996 issue of the APA’s Psychiatric Practice & Managed Care, and appears here reprinted with permission of the APA.

The prospect of denial of coverage of certain treatments is, unfortunately, inherent in managed care systems. To assist APA members with appeals of such denials, we recommend the following.

  1. Request a copy of the utilization review (UR) criteria and appeals procedures upfront. Review them before any UR or appeal activity and follow all procedures.
  2. Be nice. Although this may seem to be very basic advice, getting off on the wrong foot with an MCO staff member may doom your case, your future cases, and potentially your “participating" status.
  3. Ask for the case manager’s credentials and insist on peer review if there is a disagreement. Denials should be made only by psychiatrists.
  4. If you are denied certification, request a written explanation and a description of the information required for approval. This summary enables you to reduce ongoing, contentious dialogue. It also ensures that your subsequent submissions “fit the bill" -- you avoid providing extraneous information and making unnecessary compromises.
  5. If your appeal is denied, appeal again. Most MCOs offer three or four levels of appeal, but many give up after one appeal is denied. In addition, it is highly advisable to exhaust all appeal mechanisms before initiating any litigation, should you be forced to proceed in that manner.
  6. Meet all UR and appeal deadlines. If you do not, the merits of your case may not matter. Certification denials due to “administrative noncompliance," e,g., missed deadlines, are rarely overturned.
  7. Include any literature that supports your case for the proposed treatment approach. A little extra demonstration that you are an expert on the subject-and are supported by other experts-never hurts.
  8. Focus on the treatment goals and how you are going to meet them. Promote the fact that you have an “action-oriented" approach.
  9. In an emergency situation, request an expedited appeal by a psychiatrist. Most MCOs have such services.
  10. If appropriate, ask the patient to enlist the support of his or her employer in the dispute. MCOs are often more responsive to the complaints of their paying clients.
  11. When patients are slow to respond to treatment, ask the MCO to “flex" benefits by working with you to find an alternative, cost-effective treatment approach.
  12. If coverage is denied after several appeals, request an external reviewed by an objective third party. Many MCOs offer such reviews, but there may or may not be some cost-sharing.
  13. Include a “cc" to the state insurance commissioner on your appeals and complaints. Although such disputes rarely require intervention by the state insurance commissioner, seeing such a “cc" often elicits a more rapid and favorable response from an MCO.
  14. Call the APA Help Line [1-800-343-4671] for assistance. Your case will be reviewed by a member of the Managed Care Committee. If there is a clinical rationale supporting your case, the Office of Economic Affairs and Practice Management will contact the MCO’s medical director on your behalf. If there is a pattern of unreasonable denial with a particular MCO, staff may also arrange for a meeting with the MCO’s executives.
  15. Contact any other professional organizations you may belong to and any consumer advocacy groups that may be helpful. A complaint lodged by several parties will be stronger.