Each person deserves the fundamental rights and access to healthcare. However, every so often, you will find an individual who does not know his or her unequivocal rights when seeking treatment or during their course of care because those rights are usually ambiguous or too detailed to comprehend. It is not uncommon for medical claims to be denied particularly for patients who cannot afford to pay for their treatment. Patient rights can be extensive and exist among various people and institutions, between any medical caregiver, hospitals, laboratories, insurers in particular. Understanding the reasons why medical claims get denied can help limit the number of denials your doctor’s office receives.
It is customary for many services considered as non-emergency related to require prior authorization. Additionally, specific surgical procedures and inpatient admissions may also require prior authorization, and such services will likely be denied by the insurance payer. However, services such as life-saving weight loss surgeries will not be denied if they are deemed and considered as a medical emergency. Here are additional reasons why claims are denied are:
- Insufficient medical necessity – Many carriers require evidence that reveals the safety and effectiveness of the procedure
- A claim may be denied because it is missing information, such as a service code
- Claims can be denied due to outdated insurance information
- A request is likely to be denied if it was filed too late
- When the expected medical service is not covered by the patient’s insurance company
Many denials are recoverable given the proper tools. That said, unless an obese individual passes the criteria for medical necessity using bariatric surgery for weight reduction such as; having a BMI greater than 35, has at least one co-morbidity and has a letter from their physician recommending or supporting weight loss surgery, denials of coverage for bariatric surgery are often a frequent source of appeals.
This is because some insurers specifically exclude all weight reduction surgery because of the difficulty of defending case-by-case denials on appeal, which is where a letter of medical necessity comes in.
The definition of ‘Medical Necessity’ according to the accepted standards of medical practice is the “health-care services needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms that meet accepted standards of medicine. Denied services, particularly those that require prior authorization must pass as medically necessary.
While a physician’s opinion largely dictated medically necessary coverage and were rarely challenged by insurers before, today, the opinions about whether a particular service, test or procedure is medically required lays with insurers who determine what goods and services they will pay for and gives them the power to dictate professional standards of care for all patients.
Therefore, for a service to be declared as a medical necessity, it needs to be factual, reasonable and crucial to treat. A medical necessity letter from a physician or provider should include the following:
- The letter of medical necessity must state the patient’s details, the specific reasons for the claim denial, their last date of evaluation and pertinent medical history documenting why the requested treatment is medically necessary
- It must explain why they need the surgery and how being obese has impacted their life
Mention all the significant adverse symptoms from their obesity, which can be anything from sleep apnea, stress incontinence, diabetes, high blood pressure, gastroesophageal reflux disease, high cholesterol, arthritis, depression, chronic skin problems, to mention a few
- Discuss in detail the severity of the illness including diagnosed signs and symptoms and the probability of an adverse outcome if they do not get the surgery
- Mention all their attempts to lose weight including dieting and exercising
- Why the treatment is recommended over other alternatives and how it would alleviate their current condition
- You may also need to include the need for a wheelchair due to impaired mobility
- Mention all the reasons why a bariatric patient needs the surgery and how it will change their life to make a resounding case and have logical conclusion
- Provide any documentation of all medical care you have accorded them for their weight-related condition
By submitting a letter of medical necessity, a bariatric patient certifies that the expenses they are claiming are a direct result of the severe obesity, and they would not incur the costs they are arguing if they were not treating this medical condition. It should, therefore, be unique and make sure the letter is individualized as it lends the letter a greater sense of authenticity.
It should also provide an accurate description of a patient’s physical presentation and abilities including how their current function and development has been negatively impacted by his or her disability. When trying to make a case for medical equipment, the letter must demonstrate why this piece of equipment is the best choice over the others regarding optimal support, adjustability to meet a bariatric patient’s needs, and how it will improve the patient’s overall life mobility-wise be it in or out of equipment.
It is, therefore, vital to paint a picture of understanding of the equipment for which you are seeking approval using only those terms that can be understood by an ordinary person instead of getting caught-up using acronyms and other difficult abbreviations that are only medically comprehensible.
Obesity poses a lot of challenges to an individual’s life and imposes significant costs on the healthcare system due to its association with various medical conditions that have reached crisis proportions. While it should be readily preventable, unfortunately, it isn’t, and its predominance is responsible for about 5% of all major deaths worldwide. Obesity is the result of numerous factors, and as we continue to look for effective ways of tackling each element, interventions such as bariatric surgery to reduce stomach capacity will remain the one solution that serves to encourage and empower obese individuals to make the required lifestyle changes and also to ensure that the changes are sustainable as efficiently as possible.