Jon, you are all over the map, and need a more focused approach. Firstly, Steve might be right, but he might just as well be wrong. This process is carrier dependent, and state dependent, so what works in Georgia might not work in North Carolina. Louisiana workers comp, for instance, does not allow for specialty specific appeals.
I have a 90 percent approval rate, both with comp, and third party payers. Attorneys have learned this, and send these kind of cases to me, specifically when other guys can't get authorization.
I know it's boring, but at some point, you have to learn the rules. They're not hard to find. Do a Google search and read them. Read about the process, and about the specific criteria for each procedure you want to do. When you have a peer to peer, know them cold, or have them in front of you. The paid shill on the other end of the phone doesn't know them better than you, and often doesn't know them at all. Educate him. explain politely how he's either miss reading the rules, applying the wrong rule, or not recognizing that there are other components of the rules that apply.
This is a multi-step process. Step 1 is, does it meet the specifics listed in the rules. If you can figure out a way that it does, even if the ***** the other side figured out a way to deny it, you can explain to him why the rules allow for it to be done. This is not the time to tell him why the rules are wrong. His job is to say yes or no based on the rules.
Typically, there are one or two appeals allowed. Again, this is state specific, but at some point in these appeals, you can start to challenge the underpinnings of the rules. Typically you do so by requesting a variance. In Louisiana, the rules about variances are very specific; the articles have to be newer than the ones the rules were based on, and of higher quality.
Thursday I have a peer to peer about a CESI I have a question. The reviewer was an General orthopedist from Shreveport. patient had a C3/4 posterior herniation, with lower neck and bilateral shoulder girdle generalized aching, as well as circumferential bilateral upper extremity numbness, paresthesias, and occasional sharp shooting pains. He was referred to me after having undergone 6 weeks of physical therapy and medication management under the direction of his primary care physician His first argument was, that without muscle weakness, were an EMG, there was no evidence of radiculopathy. I pointed out to him that, while radiculopathy is one criteria based upon which a CESI can be be authorized, our guidelines also allow for radicular pain , or even axial pain in combination with an annular tear to justify the performance of a CESI .
His next argument was, if a lesion is a C3/4, why are you doing the injection in C7/T1. This is where I sigh, roll my eyes, and then try I try to explain basic pain management 101.
The reviewer ultimately said that sounds good to me, I'll try and do everything I can to get this authorized. I have learned however, that good percentage of the time they will still deny, based on criteria that you haven't even discussed with them. So I always ask, as my last question, is there anything else that we need to discuss that might prevent you from approving this. The reason this is important is that, if they say no, and then do it anyway, they have now overtly lied. This is grounds for obtaining interest, penalties, and attorneys fees.
Got the written authorization via fax later that afternoon.
