Appeals: the last word.
Appeals of denied precertifications have not received much attention from the managed care industry, in part because of ERISA's favorable liability climate. However, recent court cases, new accreditation standards, and increased incentives to physicians to economize on resource use may compound the risk inherent in commonly used appeals practices for both standard and investigational protocols. This article will review some common but high-risk appeals practices and suggest low-cost protocols that can virtually eliminate risk while increasing enrollee satisfaction.
Lewis
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Peer Review Analysis, Inc., Boston, MA 02116.
D000068:Accreditation / Q000592:standards; D002985:Clinical Protocols; D007345:Insurance Claim Review / Q000331:legislation & jurisprudence* / Q000592:standards; D016365:Liability, Legal; D008329:Managed Care Programs / Q000331:legislation & jurisprudence* / Q000592:standards; D017008:Negotiating; D012308:Risk Management / Q000379:methods; D014481:United States; D014600:Utilization Review / Q000331:legislation & jurisprudence* / Q000592:standards