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 Using
URAC To Curb Denials And Appeal Claims
The American Accreditation Healthcare Commission/URAC has established
rigorous standards for utilization review which many carriers must follow.
The standards were developed to ensure that appropriately trained clinical
personnel conduct and oversee a timely and responsive utilization review
process and that medical decisions are based on valid clinical criteria. The
standards apply to accredited members of URAC and to organizations which
fall under state mandated URAC compliance.
Some of the more protective aspects of the standards are not widely known
among medical providers and, therefore, carrier noncompliance to URAC
standards is not widely tracked and its seriousness is not fully understood.
However, instances of noncompliance can seriously compromise the carrier’s
ability to defend a denial because, much like our justice system, any
failure to follow established procedures for every participant in the
process indicates an inherent unfairness in the process. If the process is
not conducted consistently, then the results become suspect. As a result,
carrier noncompliance to utilization review standards is a very valid
argument for requesting a higher level of review and, ultimately,
reconsideration of subsequent denials. Further, noncompliance should be
considered at each managed care contractual negotiation and ongoing problems
brought to the attention of compliance officers for the carrier.
FAILURE TO PROVIDE PEER REVIEW WITHIN ONE DAY OF DENIAL
URAC Standard 22 requires that any refusal of certification be followed by
the opportunity for the attending physician or ordering provider to review
the clinical information with a clinical peer with the same training as the
requesting physician or provider. If a request for peer-to-peer review is
made, the conference must take place within one business day. Further the
clinical peer must be a physician or other health professional who holds an
unrestricted license and is in the same or similar specialty as typically
manages the medical condition, procedures, or treatment under review.
Generally, the individual must be in the same profession, i.e. the same
license category as the ordering provider. The Commission states it strongly
believes that a good faith effort must be made by UM organizations to
achieve the objective of informed discussion between the providers and
reviewers of services and, to this end, it requires that decisions not to
certify only be made by clinically qualified (same licensure category and
board certified) as the physician or provider recommending treatment.
FAILURE TO GIVE WRITTEN NOTICE CITING "PRINCIPAL REASON(S)"
URAC Standard 31 requires that notices of non-certification decisions must
state in writing the principal reasons for the decision. Further a principal
reason must be a clinical or non-clinical statement describing the general
reasons for the non-certification and must be more detailed than "lack of
medical necessity" and the clinical rationale must be provided upon request.
ISSUING OVERLY BROAD MEDICAL RECORDS REQUESTS
URAC 44 states that organizations conducting prospective, concurrent and
retrospective review must only collect information necessary to certify the
admission, procedure or treatment, length of stay, or frequency or duration
of services. Organizations are prohibited from requiring hospitals,
physicians, and other providers to numerically code diagnoses or procedures
before consideration for certification. Further, if medical records are
requested, organizations are directed to be specific regarding what portion
of the medical record is required.
FAILURE TO ABIDE BY REQUIRED DEADLINE
URAC Standard 6 requires organizations to respond to communications from
providers and patients within one business day. An initial UM decision must
be made on prospective review within 72 hours of a request involving urgent
care and within five calendar days of a request involving non-urgent care.
Retrospective review decisions must be issued within 30 calendar days of the
request and concurrent review must be decided in 24 hours of the request for
urgent care and four calendar days of a request for non-urgent care
(Standards 24-26). Standard appeals must be completed in 30 calendar days of
the appeal and expedited appeals must be completed no later than 72 hours
from the initiation of the appeal (Standard UM 41).
HOW DO I DEMAND COMPLIANCE AND USE NONCOMPLIANCE IN APPEALS?
URAC provides education opportunities and onsite inspections in an effort to
ensure compliance with these standards. They also review complaints filed
against members. However, your best protection is awareness. If you are
aware of the standards that must be followed and cite the standards in phone
calls and request letters to the carriers, you will establish your office as
progressive, informed and unwilling to accept a poor quality review of
requested treatment.
Step 1 - Download the URAC Health Utilization management Standards.
Read them yourself. The State of Illinois is one entity that has enacted
URAC compliance for UR companies operating in the state. They provide an
online copy of the standards to encourage consumer use.
Step 2 - Find out if your state recognizes URAC accreditation. Even
if they do not, the majority of the major insurance carriers are accredited
organizations that have voluntarily agreed to the guidelines. A member
directory is available at URAC.org and also contains information for each
organization’s compliance contact person to whom complaints should be made
regarding noncompliance issues.
Step 3 - Make it a point to request peer-to-peer conversation on any
certification denial and remind the carrier of the 24-hour deadline. If the
carrier does not provide peer review as required, explain that this
noncompliance seriously compromises their ability to defend any
noncertification if an appeal is filed with the state independent review
process or if the matter is litigated. Routinely note in patient records any
noncompliance with URAC guidelines. (See Peer-To-Peer Conversation Request
Letter Under Medical Necessity/URAC Regulations in the
AppealLettersOnline.com letter repository.)
Step 4 - Always require carriers to provide written notification of a
certification denial and specify that you are particularly interested in the
principal reason(s) for the decision. You may have to actually provide
URAC’s definition of principal reason that makes it clear that “lack of
medical necessity” is not an adequate response. (See Lack of Written
Decision letter Under Medical Necessity/URAC Regulations in the
AppealLettersOnline.com letter repository.)
Step 5 - Review medical records requests with a sharp eye for
unnecessary and overly broad requests and again, do not hesitate to send
carriers actual copies of the URAC standards when you feel the carriers are
not in compliance. (See Records Request Response letter Under Medical
Necessity/URAC Regulations in the AppealLettersOnline.com letter
repository.)
Step 6 - Review any non certification or unfavorable appeal responses
for compliance with URAC decision deadlines. Every appeal letter regarding
the treatment should include a reference to any failure to respond within
these time frames. Make it clear that the ordering physician does not have
the benefit of such leisurely reviews. (See Lack of Timely Decision and Lack
of One Day Response letters Under Medical Necessity/URAC Regulations in the
AppealLettersOnline.com letter repository.)
And if that does not work . . .
URAC.org has online complaint filing. Member profiles also list executive
level representation from member organization who are responsible for
compliance. Send complaints directly to compliance officers with the
carriers. |
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