Calling @AlmostAnMD

[RustedFox]

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Hey; you're the man for this job, @AlmostAnMD

I remember seeing some short-form video or article about what exactly to say when insurance calls you (or you call them) after a claim is denied for (procedure, etc).

I made this an open thread for anyone else to comment/help.

Steps like: "Okay, I'd like the exact reason for this claim denial - the credentials and the NPI of the person making this decision, the claim number, the supervising director, and the *whatever else data you need*."

 

[AlmostAnMD]

Hey; I dunno about that semicolon

So others in this line of work can comment on their own thoughts/approaches etc. Here's some rambling thoughts of mine

Medical necessity isn't really a one-size-fits all approach thing. Laws vary by payor type (commercial, medicaid, medicare, etc) and inside individual payors they add some weird loops

I assume, generally, you're talking about yourself and/or docs here, and all of us probably have some "real" commercial insurance.

So angling from that, what you said may have been relevant in the past but realistically and especially after Brian Thompson was sacrificed to the capitalism gods denial letters are often unsigned. Basically everything you're asking for you probably won't get.

You can get "board certified in internal medicine" or their initials or something but rarely will you ever get a name now.


The denial letter should, in theory, have a reason on it. Often it's a canned response related to some bull**** guideline (MCG, InterQual) and how your request didn't meet that guideline.

Maybe it does meet the guideline? You can always ask to see the full criteria set (they can't say no) and see if you can pigeon hole yourself into it and say how in the appeal.

Increasingly, insurance companies are unreasonable dinguses. So even if you have a valid reason, or it even meets whatever criteria, they may deny the claim and the appeal.

All commercial appeals can go to a second level independent review. I just helped a friend's mom do this for her alzheimer med (BCBS said it was experimental and denied on these grounds, the independent reviewer agreed with the neurologist that rec'd the drug that it had a valid use and patient may benefit)

Independent review is awesome. As long as you can articulate a good reason you can typically win, especially if the doctor that recommended the procedure/drug write a clear letter explaining why it is medically necessary

eff insurance directors. Just from talking to them it's pretty easy to understand most of them were probably like Leslie Nielsen Ala Naked Gun in whatever specialty they were before they went all sith

 

[Apollyon]

Independent review is awesome. As long as you can articulate a good reason you can typically win, especially if the doctor that recommended the procedure/drug write a clear letter explaining why it is medically necessary

I remember someone, maybe @gutonc , posting about a "peer to peer", and actually got their subspecialty peer on the phone. Easy peasiest call ever.

 

[AlmostAnMD]

I remember someone, maybe @gutonc , posting about a "peer to peer", and actually got their subspecialty peer on the phone. Easy peasiest call ever.

Yeah we used to do a lot more of those but because p2p is "unofficial" and appeals are "official" I've been avoiding those

If it's a straightforward case that has an easy explanation asking for a p2p is reasonable. My post probably reflects my attitude in general about them since I don't do them often anymore but they still have some value/can win stuff

 

[RustedFox]

@AlmostAnMD

Hey; I'm sorry about that semicolon. I have an affinity for them. You're correct.

I'll PM you. Let the fires burn here.

We need real insurance reform in this country, or else (not me), there's going to be more Luigis. I don't want that.

 

[BoardingDoc]

I remember someone, maybe @gutonc , posting about a "peer to peer", and actually got their subspecialty peer on the phone. Easy peasiest call ever.

I did a lot of P2Ps in fellowship. I've now completely stopped. It isn't because they don't work (they frequently do, and I got most of my P2P requests approved). It's because they tell you to call some number and best case scenario is that you wait on hold for 20 minutes before talking to someone. More common case is you wait 15-20 min then some call center person says the doc will call you back within a certain time window when I'm almost certainly with a patient and can't come to the phone.

Now I refuse all P2P and tell them to simply send me the denial letter. I then pick it apart, send it back to them explaining why they're an ignorant asshat, and it gets approved.

That said, in my current gig, I know all the required criteria for basically everything I order like the back of my hand and the denial reasons are either things I can easily fix, or it's denied for not meeting criteria.... when it obviously does.

 

[AlmostAnMD]

Yup. Again, for some things a P2P may not be offered (there actually is ZERO legal backing for them, and ZERO regulation!) and often it is.

@BoardingDoc has a niche thing he does that makes P2P very attractive and his win rate is probably great.

Myself, a lot of what I do ends up being highly combatative/contentious and deeply nuanced inpatient medical necessity stuff.

I'm lazy. I want to be efficient. If I spend the time to do a P2P and I fail, I end up doing an appeal. So it's just easier for me to do the appeal. Also, I'm lazy (again). I don't want to write the appeal. So when a denial comes I just drop the entire chart into my Opus prompt I've custom-made, tell it the insurance type so it pulls in all the regs, and it spits out the appeal.

That still doesn't work sometimes. I'm going to court twice this month over failed appeals. I'm a highly, highly vindictive person towards insurance. I literally lay in bed some nights and fester over how I can screw these jerks even harder. All they do is commit fraud and taking them to the cleaners over it is deeply cathartic.

**** insurance

 

[wysdoc]

There was a good thread about writing appeals to denial letters here in the Pain forum Anyone using ChatGPT for Insurance Appeals?

 

[gutonc]

I remember someone, maybe @gutonc , posting about a "peer to peer", and actually got their subspecialty peer on the phone. Easy peasiest call ever.

Once, and only once, did that happen.

I now just use Copilot to write the appeal letter. I include the diagnosis, the test/drug, the insurance company and guide it to the resources I want it to use (NCCN guidelines in my case) to support it.

I'm batting 1.000 with this technique over the past 6 months or so.

If they're going to AI deny me, I'm going to AI appeal them and let the algorithms fight it out. I've got better s*** to do with my time.

 

[AlmostAnMD]

Once, and only once, did that happen.

I now just use Copilot to write the appeal letter. I include the diagnosis, the test/drug, the insurance company and guide it to the resources I want it to use (NCCN guidelines in my case) to support it.

I'm batting 1.000 with this technique over the past 6 months or so.

If they're going to AI deny me, I'm going to AI appeal them and let the algorithms fight it out. I've got better s*** to do with my time.

This is the way