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How to Be Proactive After a Medical Denial

 

Learn how to respond to a denial adequately and professionally to increase your chances of a denial being overturned.

Medical denials come in various forms from the type of denial to the party making the adverse determination. When a medical provider receives a denial, it commonly includes limited reasoning justifying the denial and a summary of appeal rights afforded to contest the decision. However, even with the receipt of this information, the medical provider may not understand how this process works or how to present an adequate response to the denial. It prepares a submission that only responds to the initial basis of the medical denial not realizing an extended appeals process offers the party issuing the denial an opportunity to utilize other justifications for the adverse decision. It may not comprehend requirements as to how to submit evidence refuting the denial. Furthermore, a medical provider may not understand the long-term implications of failing to respond adequately to such a denial. One may overcome these issues by being proactive in addressing medical denials. This topic explains the medical denial appeals process and how one should proactively prepare their case to take advantage of the opportunities afforded to them. It will also describe in detail how to present a response to address the initial denial, how to proactively anticipate and circumvent in advance subsequent reasoning that may be used against the medical provider and ensure that a waiver of appeal rights does not occur. This information will assist those individuals responsible for responding to medical denials to develop and implement best practices by illustrating examples of approaches to take when creating standard operating procedures for responsive actions. Failure to do so may result in submission of insufficient evidence to support the medical provider's argument or even result in a waiver of a right one is guaranteed under law or by contract. This material is critical for medical providers to adequately approach, prepare and present their reasoning and evidence to support their argument that the medical denial should be overturned.

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How to Be Proactive After a Medical Denial

Agenda

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How to Be Proactive After a Medical Denial

Faculty

Patrick D. Souter

Patrick D. Souter

Gray Reed & McGraw LLP

  • Of Counsel, Gray Reed & McGraw LLP
  • Representation of physicians, hospitals, and ancillary providers in operational, regulatory, and administrative matters
  • Board certified in health care law by the Texas Board of Legal Specialization
  • Adjunct professor of health care studies at Baylor University School of Law and frequent speaker to national and local health care organizations
  • Recognized as a leading health care lawyer in Texas by Chambers & Partners USA (2020) and selected by his peers for inclusion in Woodward/White, Inc.'s The Best Lawyers in America in the field of health care law (2019 - 2021)
  • Frequent author of books and articles for the American Health Law Association (AHLA) and American Bar Association (ABA) including co-authoring the AHLA’s Representing Physicians, 4th edition and the ABA’s Physician Law Evolving Trends and Hot Topics (2017- 2020 editions) and What is ... Medical Staff Peer Review?
  • Frequent speaker on physician, hospital, and other provider issues
  • Member of the American Bar Association, State Bar of Texas, American Health Law Association, American College of Healthcare Executives, and Health Care Compliance Association
  • LL.M. degree in health law, Hofstra University; J.D. degree, Baylor University School of Law; M.B.A. degree in health services management, University of Dallas
  • Can be contacted at 214-954-4135, [email protected] or 1601 Elm Street, Suite 4600, Dallas, Texas 75201
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How to Be Proactive After a Medical Denial

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