What does this have to do with legal and rule-based arguments? Well, anyone who utilizes ODG as a rationale for denial must cite the guideline which has been exceeded.

If they do not, the review is in serious jeopardy of not being utilized. That is, if someone (you) who knows the rules makes the governing body in charge aware of the violation.

This leads to another truth you must all recognize and understand; the governing bodies in charge do not always know the rules. Sometimes, they must be instructed. Do this for your patient.

As an example, let us return to the BWC example for a moment. Reviews are performed by doctors regularly as an attempt at peer review and oversight. This is not always successful. It is not uncommon that a review will come back denying care based on a host of reasons; "treating non-allowed conditions", "no lasting therapeutic benefit", "care exceeds established guidelines", and the list goes on.

What many do not know is that none of these reasons, in regard to the Ohio BWC, are allowed to be used in the determination of care allowance. I don't mean to suggest that every state's BWC program follows these rules. It is merely a way to show you the power of such knowledge. Understanding the systems within which you work and knowing the rules and how they are used both for and against you is paramount to maximizing the therapeutic benefit your patient receives.

Let us switch gears for a moment, back to the national third party payer system. Insurance companies nationwide all have rules they are legally obligated to follow for the determination of care. This does not prevent them from listing some of their own "arbitrary controls" as rules.

As referenced in a previous article I wrote, when your company purchases a plan for its employees, that plan must be upheld and followed to the letter. This is not always done.

The largest oversight usually revolves around the maximum number of visits allowed by the plan. Many now contain visit limits. Some base the need on medical necessity. It is important to know which each plan involves. This saves you time and money and, more importantly, keeps you from plumbing a dry well.

If the patient has 12 visits allowed in the summary plan document, then that is what they have and no amount of appeal will be successful. You may have gathered that oftentimes you will find that a service is a covered benefit and is being denied as though it is not.

This "oversight" is common within the system and only knowing the rules and being able to accurately quote them will allow you to prevail in the determination of treatment or care allowance. Sometimes, it is as simple as calling the third party payer on the phone, making them aware of the oversight and solving the problem right then and there. It isn't always this easy, but it is always a good starting point. Some of the information contained herein may be old hat to many of you. If that's the case good job keep reading and learning.

More importantly, make that information available to others. State and local organizations are always looking for knowledgeable DCs to help mentor younger more recent grads.

Where to Begin

So, you're ready to expand your knowledge. Where to begin?

The first place to look is within your own ledger. See where you are getting the most consistent denials, or for which services you are often denied. Look into the current guidelines surrounding these services.

Call the payer who is denying the service and ask them what guidelines they are using to make their determination. Review the guideline and see if you are within them. It is possible to quote another comparable reference, but it is unlikely that the person on the other end of the line will acknowledge it.

This may seem like a lot of extra work to get paid for a service that should be, or is covered. This is how things are today.

The more larger question is how do I find the time to keep track of all of this. I cannot tell you what to do or what may or may not be right for your practice. All I can do is tell you what others have done. Some offices simply hire someone to manage this aspect of the practice.

Some large offices have multiple individuals devoted to this realm of the practice. Others add this to the job requirements of their billing staff. This often works for mid-sized offices as the billing people are already deeply involved with the third party system and many have coding degrees and certification. If you are a small office, you may have to do this yourself.

This may seem daunting, but as the system becomes more and more complex it will become vital to protecting your ability to make an honest living and to render the treatment your patient needs, when they need it.

• Learn the rules.
• Study the guidelines.
• Read the current research and who wrote it.
• Read who has adopted it.

If you disagree, get involved. Write to the author and question. We must stop sitting on our proverbial hands as a profession. We need to spend more time setting policies that effect us and less time reacting to policies set by someone else. This is the only way we, as a profession, will survive and thrive.

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Dr. Daniel E. Wills, a 2004 graduate of Palmer College, practices in Columbus, Ohio, as part of a large group practice. His primary professional interests include peer and utilization review and the Ohio Bureau of Workers Compensation. He currently focuses on overturning improper file reviews. He can be contacted at .