APA Outlines Strategies for Appealing Care Denials

Psychiatrists who appeal managed care denials of treatment coverage should use a combination of strategies to obtain the best results, according to APA's Office of Healthcare Systems and Financing.

APA members continue to complain to the Managed Care Help Line that managed care companies deny treatment coverage on a regular basis, according to a report released in May by APA's Office of Health-care Systems and Financing. Sandra Hass, editor of Psychiatric Practice and Managed Care, wrote the report based on data collected by the Office of Healthcare Systems and the Office of Psychiatric Services.

So far in 1998, there has been an average of six denials per month for coverage for outpatient, continuations of inpatient, and disability-related treatment. This compares with four complaints per month for reimbursement rate problems and three for reviewer problems, the report states.

To address denials of care effectively, APA members should use the following strategies:

• Request and review a copy of the managed care company's appeals procedures and utilization review criteria before initiating an appeal.



• Ask for the case manager's credentials; denials should only be made by psychiatrists.



• Request written notification of the reasons for denial and a description of the information required for treatment approval.



• Ask for names and addresses of people who need to receive applications for an appeal. Find out the managed care company's deadline for appeals.



• Meet all utilization review and appeal deadlines. If a case is denied on an administrative basis (such as not following precertification procedures), explain any extenuating circumstances in an appeal.



• If an appeal is denied, try again. It is best to exhaust all levels of a company's appeal process before considering initiating litigation.



• Be concise. Do not send more patient information than necessary, and get permission from the patient to release that information.



• Request peer review by a psychiatrist trained in a subspecialty relevant to the patient's care (for example, child psychiatry).

The Office of Healthcare Systems and Financing also suggests relating the level of care requested to the patient's condition. For example, for inpatient treatment, mention any self-injury or assaultive behavior and special treatments the patient received such as suicide restraints and seclusion.

Providing relevant literature showing positive outcomes and evidence of similar cases approved by the same plan and describing the next step of treatment, including goals and approximate timeframe, also strengthens an appeal.