Optimize Appeal Decisions

Medical Directors need relevant Information.

Health plans must identify the key pieces of information Medical Directors will need in order to optimize appeal decisions for enrollees, thus improving the member experience. Denials often occur — not because the member didn’t need the service or medication — but because the Medical Director did not have the relevant information to make an informed decision.

Denials could have a negative impact on the health of the member, which is why it’s critical to ensure health plans set up processes and systems that don’t put the Medical Director in a difficult position that may result in denying an appeal due to lack of information. In addition, if the IRE overturns a plan decision, it will negatively impact a health plan’s Star Ratings.

There are five key pieces of information which should be provided in making appeal decisions:

  1. Initial Denial Information
  2. Medical Records
  3. Appeal Justification
  4. Peer-to-peer information
  5. Appeals Workgroup Meeting notes

One more important note:  For partially denied or denied appeals, it’s a best practice to review the language used by the appeal decision maker in their rationale and, if needed, edit the content to make sure that the written language can be understood by the member.

To learn more about each of these five areas and more click on the E-Book link below.
Access A&G Department eBook