Second, the Act provides opportunity for the physician, as health care provider, to stand in the subscriber's shoes in grieving and to act as the subscriber's advocate in formulating what will ultimately be a final decision based upon medical necessity. The latter may not be welcome to physicians whose primary concern is the practice of medicine rather than administrative law. There is, however, more than an ethical or altruistic interest in assisting in grievance pursuit, since establishing a right to coverage means that the physician may pursue the desired course of treatment and, in the case of a specialist, be paid for it. But such assistance, in health insurance, appears not mandatory. Physicians who choose to draft letters, beyond the medical record, focusing on the legitimacy of health services denied, should bear in mind some elementary principles of advocacy.
Argument contemplates specific delineation of the reasons for a conclusion.
Thus, if the denial relies on lack of medical necessity, the physician should articulate every clinical reason why medical necessity exists and only then conclude that it exists. Second, advocacy contemplates defeating the arguments of the opposition. Accordingly, a letter drafted by a physician in aid of coverage should specifically address the reasons, if any, given by the plan for denying coverage and rebutting them from the medical record or by professional opinion, with possible citation to journal articles. An additional physician protection the Act provides for is prompt payment, i.e., within 45 days of receipt, of a clean claim submitted by a provider. If a plan fails to timely pay a clean claim, the Act provides for ten percent annual interest.