Concurrent Care Denials Sample Letter



Provider Appeals Department
City, State, ZIP Code

Re: Denial of claims with concurrent care


Health Plan ID Number: Group Number:
Insured/Plan Member: Patient Name:
Claim Number: Claim Date:

Dear Sir/Madam:

[Insert org name here], is deeply concerned about [Ins. Co's name] policy of concurrent denials of claims when multiple providers are involved in a patient's care on the same day.   Denying or delaying payment for services rendered by providers supplying cost effective, medically appropriate care is short sited and potentially dangerous to patient care. While providing payment seems intuitively correct, there may be other reasons for you to reconsider your policy on this matter.

The 2005 CPT manual has deleted the -75 modifier and places no specific reporting requirements for concurrent care.  The Medicare Benefit Policy Manual, Chapter 15 entitled "Covered Medical and other Health Services", specifically addresses concurrent care by different providers on the same day of service in Section 30 (E).   A carrier must consider that a patient's condition warrants the services of more than one physician, and that the individual services by each are reasonable and necessary. "The specialty of the physicians is an indication of the necessity of concurrent services…it would not be highly unusual for concurrent care performed by physicians in different specialties..."

The Aetna settlement in U.S. District Court of Southern District of Florida of May 21st, 2003 clearly describes some   "key" business practices mandated in the settlement regarding the definition of "medical necessity". Medical necessity shall mean healthcare services that a physician exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease.

The Emergency Treatment and Labor Act mandate hospitals and emergency physicians to provide medical screening exams and stabilization treatment for patients who present to the Emergency Department.  State laws which contain "Prudent Layperson" standards for payment of Emergency services, prohibit the practice of routine denial for appropriately provided and coded claims by emergency care providers.

We strongly urge you reconsider your policy of denial of payment of these services to comply with existing state law, prior legal precedent, and accepted insurance standards.


(Your name here)


Source: AMA

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