Why clinical facts and sound reasoning aren’t always enough—and what it takes to craft a compelling, clinically defensible appeal.
In denials management, reactions often become emotional when they should be logical.
Defeating a denial requires a methodical, step-by-step approach to clinically disprove the flawed position.
Yet even the most logical, fact-based appeals can end with an upheld denial. Why?
Have you ever wondered why? I think there are several reasons:
- Time and incentives: Unless someone is genuinely passionate about the right care, right setting, right time, right cost philosophy, the time and effort required to to rigorously adjudicate an appeal may not be commensurate with the compensation.
- Variability in clinical expertise: Not all clinicians bring the same level of clinical knowledge, experience, or depth of understanding to the review process.
- Variability in physician review skills: Not all physician reviewers possess the same level of clinical scrutiny, issue-spotting ability, critical thinking, or written communication skills needed to identify flawed facts or reasoning and formulate a defensible rebuttal.
What can we do about it?
Here is what I believe can make a difference:
- Anticipate the reviewer: Recognize that your appeal may land with someone who is pressed for time, has variable clinical expertise, and may not immediately recognize the flaws in the denial’s clinical reasoning.
- Make the clinical argument unmistakable: Present the relevant facts, connect them through clear clinical logic, and explain precisely why the denial’s rationale is flawed.
- Anticipate the counterarguments: Address the likely objections before they are raised. Do not leave the reviewer to reconcile conflicting facts or construct the rebuttal themselves.
- Make the rebuttal defensible: Provide the clinical rationale, supporting evidence, and appropriate references needed to justify overturning the denial. Simply asserting that the determination is incorrect is rarely enough.
- Make the reviewer’s job easier: Essentially, package a turnkey, well-reasoned, clinically defensible argument for the reviewer. Do this with the recognition that the reviewer may have limited time, may rely heavily on InterQual or MCG, and may lack the resources or latitude to develop a more nuanced argument independently.
The bottom line
Don’t just demonstrate why the denial is wrong.
Present the clinical evidence and reasoning so clearly that the reviewer can readily understand, articulate, and defend the rationale for overturning it.
Being right is important. Making your case impossible to misunderstand is a different skill altogether.
Disclaimer: These are my own views, shaped by my experience in clinical utilization review — not the position of any employer, client, or organization I’m affiliated with.