What suggestions would you give for other providers submitting claims? You need to know what the insurance company requires in documentation to have approval for these cases and, if it’s possible, try to identify your most restrictive set of criteria. If you can figure out which insurance company requires the most in terms of documentation, then try to consistently provide that information in your notes across the board.


Usually they will list certain criteria that have to be present before they approve a procedure, and it really helps to have those clearly articulated in your clinic notes—because then you can completely bypass the need for a medical file reviewer, as the insurance company will just approve it up front.


But sometimes I will review a case and make an argument for why the payer or insurance company should consider a procedure medically necessary, despite their policy. I will explain why their policy is incorrect or based on old data. I do that a lot for PCS and UFE.


Have you learned anything through this work that has surprised you? Yes—sometimes the process really boggles the mind. I’ll see a decision rendered by the person who did the file review before me and they clearly haven’t even read the documents that have been provided. Sometimes it’s clearly stated in the documentation that the procedure is medically indicated based on the criteria that the payer has set forth, but sometimes I guess it’s missed, or they don’t take the time to read everything. Those are pretty easy, because I can just note that the clinic notes clearly state the patient has a medical necessity. But I was surprised by how often that happens.


Who typically performs those initial reviews? Usually the first review is done by a nonphysician. If there’s a denial, it may or may not get an automatic review by a physician, sometimes an internal physician employed by the insurance company. Usually when it gets to me,


sirweb.org/irq | 27


When you’re first starting and getting used to the process and system it can take an hour, but once you’re experienced, then you can finish a case in anywhere from 10 minutes to half an hour depending on how complicated it is.


it’s on appeal, and with that they want to find an independent third party to evaluate the medical file.


What kind of time commitment is required for these reviews? I don’t do a lot, and it varies from month to month depending on how available I am and whether I’m on call. I would say on average I do somewhere between one to four cases a month. When you’re first starting and getting


used to the process and system it can take an hour, but once you’re experienced, then you can finish a case in anywhere from 10 minutes to half an hour depending on how complicated it is. There are cases you see over and over again—such as UFE or PCS—and you can use the reports that you wrote previously and essentially copy and paste them into the new report and update references as necessary.


Have you met other IRs who do review cases like this? No, but there’s definitely a demand for it. There are always plenty of cases for me to review, and I turn a lot down because I don’t have the time.


You’ve used the word charity work to describe this—why? It’s not something that you do to reward yourself financially—it definitely doesn’t pay well. I don’t think I’ll be doing it indefinitely, but I do plan to continue for now. It has been a great learning experience for me—it’s made my documentation better, because now I know from the other side what I need to document to get the best chance at reimbursement.


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40