Many times, payers deny specific patient treatments, drugs, or hospital stays due to the specific treatment or drug being considered non-covered or experimental. While these claim denials can be argued in a formal appeal on the back end, a health system can also obtain a predetermination for these treatments and drugs before a patient’s treatment.
What is medical predetermination?
Medical predetermination should not be confused with prior authorization or precertification. Prior authorization and precertification inform the payer that the patient needs a specific healthcare service, treatment, medication, or durable medical equipment. The payer then replies to the provider as to whether the service is covered under the patient’s policy. Whereas a predetermination goes a step further.
A medical predetermination is a formal review of a patient’s requested medical care by the payer. Predetermination allows a health system and the patient to know whether a specific treatment is covered in advance of the treatment.
During the predetermination process, the provider submits documentation to validate the need for the treatment. The payer reviews the documentation to determine if the patient’s upcoming course of treatment meets their medical and insurance reimbursement policies. When the payer issues approval, it can be leveraged to ensure coverage and payment to the healthcare provider. However, it’s important to note, precertification and preauthorization do not guarantee coverage and a predetermination is not a substitution for a preauthorization.
Tips for Submitting a Predetermination
Tip #1: Lean into the predetermination process regardless of timing
In many cases, the predetermination process requires a turnaround time of 30-45 days. The timing oftentimes conflicts with a patient’s course of care. However, Aspirion recommends healthcare providers continue to utilize the predetermination process. Specifically for those patients whose conditions or treatment might otherwise be deemed as experimental or non-covered. The payer’s precise clinical criteria should be identified, and your hospital should work closely with the patient’s providers to gather all documentation that demonstrates the patient meets the payer’s clinical criteria.
If the hospital is confident that its patient conditions meet the payer’s policy bulletin standards but are unable to wait to administer the treatment, Aspirion recommends that a request for predetermination with supporting documentation be submitted to the payer. Even if a predetermination is issued following treatment or denial, the hospital will be able to utilize the approval as a quick and easy means to overturn the denial and reduce their aging AR.
Tip #2: Maintain a list of experimental and non-covered services
Medicare and payers do not cover certain items and services that they deem to be experimental or non-covered. As referenced previously, payers require specific medical necessity requirements in their statute, regulations, and manuals as well as specific medical necessity criteria defined by Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs). Typically, proven procedures that meet “reasonable and necessary” requirements and are proven as safe and effective are covered services.
Working within the guidelines of payers can be tricky as the rules and regulations seem to be in constant flux. Therefore, we recommend that hospitals consider creating a working list of Healthcare Common procedure Coding System (HCPCS) and diagnosis codes that are regularly considered experimental or non-covered. Plan to review and update the lists at least quarterly per payer’s quarterly policy updates.
Tip #3: Utilize persuasion-style writing
As with formal appeals, we recommend utilizing persuasion-style writing when submitting a request for a predetermination.
Persuasive writing is used to convince or persuade a reviewer toward a specific viewpoint or action. To do so, you present information intending to inform and convince. Some of the most persuasive arguments are made when you refute key points of opposing view by dispelling arguments and published payer stances.
In the case of a predetermination, you should include evidence-backed justifications to support the patient’s care plan. This includes not only citations to the medical records and patients’ treatment plan, but also peer-reviewed literature, statutes, regulations, contract provisions, and widely accepted practices. Your arguments should be clear and concise, naturally starting with the strongest argument. Ideally, you should get the reader to agree with a stance upfront. This stance should be something that most people would have a hard time disagreeing with. Once you have the reader hooked, you should rigorously make your case with supporting evidence, all while relating to your point that has already been accepted.
We recommend the IRAC method when writing persuasively:
- Issue: Identify the issue or objective
- Rule: Cite to the appropriate resource/evidence (statute, regulation, payer policy, etc.) that supports your position
- Analysis: Show how the patient meets the previously cited to “rule”
- Conclusion: Conclude your argument by tying everything together
Utilizing this framework will help ensure you are not only addressing the medical necessity of the stay but will also ensure you are being as persuasive as possible.
Below are success stories that illustrate the importance of knowing a payers policy bulletin standards while using persuasive writing to prove the patient’s care plan adheres to its policies. In these instances, if the facility requested a predetermination before the procedures, they may have circumvented the need for a formal appeal.
Case Example 1:
- The payer denied implantation of an osseointegrated implant in the temporal bone with percutaneous attachment to an external speech processor/cochlear stimulator with mastoidectomy and a cochlear implant.
- Aspirion argued that the patient met the appropriate indications in the payer’s clinical policy requiring the services be paid. The payer approved the implant as requested by the provider.
Case Example 2:
- Payer denied surgical knee arthroscopy with meniscectomy—medial and lateral, including any meniscal shaving—including debridement/shaving of articular cartilage (chondroplasty) as experimental
- Aspirion argued the patient met all indications required under the payer’s clinical policy bulletin. The payer approved the knee arthroscopy with meniscectomy as requested by the provider.
Effective predetermination processes can be instrumental in minimizing risk and ultimately reducing A/R days for an organization.
Up Next …
In our next post, we’ll share strategies surrounding the Concurrent Review Process and No Authorization Denials.