Contacting Medical Directors of Private Payers

Typically, medical directors of health plans are responsible for the oversight and implementation of coverage policies and utilization management. Hence, establishing a rapport with the medical director of your state or regional plan is an excellent way to advocate coverage for procedures or devices, which have been inappropriately denied or bundled. Generally, private payers base their coverage policies on different methods such as technology assessments (from state or federal agencies, or independent non-profit organizations), in-house reviews of medical evidence, clinical practice guidelines, Medicare coverage determinations, and sometimes based on the cost effectiveness of the procedures or devices. As such, it is imperative that you (or your staff) consider the following factors:

• Perform a thorough search on the payer’s website for its coverage policy for the procedure in question to determine the payer’s rationale for coverage and to confirm the policy is in line with current and accepted practice.
• Ensure that you (or your staff) are aware of the specific reasons the insurer denied the procedure or service. You can do this by contacting the payer representatives to discuss your rationale for the medical necessity of the service. If this is unsuccessful (the insurer does not overturn its adverse coverage decision), proceed to the following steps (below) so that you (or your staff) can compile data to support your argument as you engage the medical director in payer advocacy.
• Determine if there is peer-reviewed literature from reputable journals that shows the benefits (such as substantial improved health outcomes, delivery of high quality of care and possible comparative cost effectiveness) of the procedure or device within a relevant patient population. (Caveat: some insurers may lag in coverage (by about five years) for new procedures that the CPT Editorial Panel and the RVS Updating Committee (RUC) have valued and approved. As a result, the insurer might still decide not to cover the procedure in question).Determine if any government agencies have conducted reviews or assessments (efficacy studies) of the procedure or device.
• Find out if Medicare has a favorable local coverage determination or national coverage determination for the procedure or device. If the payer follows Medicare guidelines, you can use this position to bolster your argument for coverage.
• Check whether the Academy has any policy statements, clinical indicators, CPT for ENT articles, Clinical Practice Guidelines on the procedure or device that you can use to further strengthen your case with the payer. Similarly, you can check the sources listed below for clinical reviews and data:

Medicare Evidence Development & Coverage Advisory Committee (MedCAC): Established in 1998, MedCAC provides independent guidance and expert advice to the Centers for Medicare and Medicaid Services (CMS) on specific clinical topics, technology, and science.

Technology Evaluation Center (TEC): Operated by the national Blue Cross Blue Shield Association and has collaboration with Kaiser Permanente, creates assessments of medical technologies based on “a comprehensive evaluation of the clinical effectiveness and appropriateness of a given medical technology.”

National Guidelines Clearing House (NGC): A comprehensive database of evidence-based clinical practice guidelines and related documents. It is an initiative of the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.

The Cochrane Collaboration: An international non-profit and independent organization that produces and disseminates systematic reviews of healthcare interventions, and promotes the search for evidence in the form of clinical trials and other studies.

Your approach to the medical director should be collegial, professional, and educational with an emphasis on your desire to provide the best patient care. When possible, try to avoid becoming confrontational, especially since other issues may arise in the future.