THE CLIENT

Large Physical Therapy Provider Network
 

THE CHALLENGE

 A large Mid-Atlantic physical therapy provider network underwent a claim-by-claim review of a sampling of 3,000 records by a major northeast property & casualty insurance company and its affiliated managed care organization. The reviewed claims represented 10% of all disputed claims [N=30,000]. The carrier’s consultant did not review the balance or 27,000 individual claims yet, extrapolated denial rationale from 3,000 and applied it to the aggregated claims. The provider network subsequently filed a lawsuit against the carrier citing numerous complaints concerning the utilization review methodology. 

Total claims denials exceeded $500,000 dollars
 

THE INNOVATIVE SOLUTION  

Our consultant was retained by a plaintiff law firm on behalf of the provider network to examine the review methodology in order to determine if medical necessity was established through a fair, reasonable and  community recognized utilization review process. 
Our consultant reviewed the insurance company’s expert report summarizing the analysis and claims denial rationale for 3,000 individual cases.  Additionally, a cd rom provided during discovery by the network containing all 30,000 cases was reviewed by our consultant. 
There was no evidence provided to our reviewer that a “peer-to-peer” or “physical therapist-to-physical therapist” review process was employed by the insurer either upon initial denial or after appeals were filed. In fact, a nurse had recommended the physical therapy claims denials. 
   
Our consultant analyzed the insurer’s “expert report” in rebuttal of physical therapy claims review methodology especially, pertinent to the claims denial appeals process, which was not articulated in written form.  Although numerous contractual documents were provided to our consultant for review, these involved “legal” issues that did not fall within the practice scope of our physical therapist consultant. In should be noted however, that the insurer’s nurse consultant liberally addressed what our consultant considered to require legal not, medical opinions.   
 

THE RESULTS/OUTCOMES

A confidential settlement was negotiated in this case and not provided to our consultant.