Utilization is a process wherein an insurer or public body requests an examination of the viability and/or medical efficacy of a medical service. This gathered data is typically used to justify refusal to pay the cost of a medical claim.
Our team assists providers in filing appeals to these conclusions in a timely and professional manner. These are happening more and more, especially in Michigan as orchestrated by the Bureau of Insurance and Financial Services with no-fault, personal injury protection claims.
The following provides guidelines given to prospective users of our Utilization Response service:
Dear Prospective User:
The response to Utilizations is an intricate process. It involves the research of competing medical data, interview of medical professionals and the compilation of medical information to refute refusals to pay claims. Often it also includes live interviews with physicians who have written orders for denied services, allowing their own words to medically substantiate their decisions.
Direct Care Training & Resource Center, Inc. manages a team skilled in these processes. The following provides the guidelines that govern our work in this area. For billing, please note that we determine the cost of each case based upon dates of services denied and the hours of work we need to invest in developing an appropriate response.
INTERNAL GUIDELINES FOR HANDLING UTILIZATION APPEALS
Client (care provider) requesting our assistance in handling a Utilization Appeal must:
- First, consider if the services are ongoing and if the amount to be pursued via the Utilization Response is worth it to them.
- Sign a one-page, per case Utilization Agreement.
- Ensure their patients are aware that a 3rd party has access to their medical information. We can provide an Attestation Statement to be mailed to the patient.
- Our team conducts any required interviews with applicable physician and physician personnel to gather information about the service in question.
- Our team pursues and reviews any medical records required to establish the basis for the service.
- Our team reviews documentation submitted with the initial claim and will make recommendations for any modifications required to re-submit.
- Our team conducts the research, consults, and assembles competing medical opinions to counteract State claims.
- Our medical team composes the final response complete with rebutting medical rationale. In the event we need the signature of agreement or approval of the service provider, we will obtain.
Our work is always completed on a case within fourteen, (14) days.
As always, we’re thrilled to provide needed support to competent and professional providers of care.
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