Risk Management

Sample Forms

Insurance coverage does not dictate clinical needs or decisions₁. Furthermore, Managed care organizations do not establish the standard of care. It is of utmost importance that physicians be the advocate for their patients and appeal a denial of care by the MCO when appropriate₂. It is also important that physicians become familiar with the appeal process. If treatment is still not approved after the appeal, it is prudent to discuss this denial with your patient.

Your recommendations of treatment need to be clear to the patient. You may need to assist patients with alternative payment options and consider reasonable alternatives to a rejected treatment plan. If your patient makes a decision not to pursue needed treatment, you then need to obtain an informed consent for refusal of treatment.

The following sample letters will assist you in both the appeal process and the informed refusal:

Sample:
Refusal to Authorize Payment

Chairperson
Utilization Review Committee

Dear ____________________

     On ____(date)____, I prescribed _____(test/procedure)____ for ____(patient’s name)____. On ____(date)____, you refused to authorize payment for that ____(test/procedure)____. I find that I must take issue with your determination for the following reasons:

(list reasons)

     In my medical judgment, a ____(test/procedure)____ is a very important part of my overall care of ____(patient’s name)____. ____(patient’s name)____ suffers from ____(describe condition)The ____(test/procedure)____ is necessary tO ____(describe why necessary)____. Failure to perform the ____(test/procedure)____ could result in the following problems:

(describe problem)

For these reasons, I urge you to reconsider your refusal to authorize payment for the procedure I have prescribed.

By copy of this letter to ____(patient’s name)____, I am reiterating my suggestion that he/she obtain the ____(test/procedure)____, despite your refusal to authorize payment, for the reasons I have set forth in this letter and in prior discussions with him/her.

Informed Refusal

Patient Name
Patient Address

     On ____(date)____, I prescribed ____(test/procedure)____. On ____(date)_, ____(name of PPO, IPA, HMO)____ refused to authorize payment for same. On that basis, you have informed me of your decision to forego the ____ (treatment/procedure)____ I have prescribed. I expressed my concerns regarding your decision during our discussion on ____(date)____ about the potential ramifications of your refusal to undergo the ____(test/procedure)____.

     The purpose of this letter is to recommend that you appeal the ____(name of PPO, IPA, HMO)____ denial of benefits and reconsider your decision to forego the ____(test/procedure)____ in light of the potential consequences of your refusal.

     Should you wish to discuss this further, please do not hesitate to contact me.

Sincerely yours,

(your name) _________

(2) Wickline versus State of California

Phone: 503-371-8228 or 1-800-243-3503
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