3 Ways to Highlight Medical Necessity & Prevent Health Plan Denials in Pediatric Therapy

Health plan denials are frustrating and time consuming. Sometimes the care is excellent, real change is happening, but the documentation doesn’t clearly paint the picture of medical necessity.

The good news? Denials are often predictable and preventable. Keep in mind, your evaluation/re-evaluation is basically a persuasive essay, where all of the content leads to a logical conclusion, the goals and dosage recommendation.

By aligning your documentation with the ICF framework, participation-based outcomes, and keeping a few other guidelines in mind, you can streamline and strengthen your clinical reasoning and increase the likelihood of health plan approval / authorization.

Check out these 3 evidence-based strategies for SLPs, OTs, and PTs!

#1: Use a systematic approach to analyzing medical necessity in the evaluation / re-evaluation process.

• • Disorder? Does your documentation show objective evidence of impairment?
  • Medical Need/Risk? Will there be a negative impact on health, safety, participation, and independence without intervention?
  • Skilled Intervention? Is the skill of a therapist required to meet the needs; needs can’t be met by a parent/caregiver?
  • Readiness? Is this an appropriate time for intervention, where the child and caregiver are able and willing to participate?

Make sure the answer to each of these questions is YES!

Consider using language like this, and make sure the rest of your documentation shows that it is TRUE:

• • “Requires skilled clinical judgment to adjust positioning due to fluctuating respiratory status.”
  • “Without skilled therapy, the child is at risk for loss of function, increased caregiver burden, and reduced ability to engage during daily routines.”

#2: Use a simple framework to create meaningful and effective SMART goals.

One of the most common causes of health plan denials is poorly constructed goals. Ferro & Quinn (2020) and Bexelius, et al (2018) identified that when therapists attempt to write SMART goals, they often end up ‘overly-engineered’ (too complex or detailed; jargon-heavy; difficult to measure progress).

Try using this 3-part goal framework to highlight medical necessity and get to SMART!

#3: Make sure your dosage recommendation is logical and reasonable based on assessment information and proposed goals.

Many denials occur because frequency or duration is not justified based on assessment information and/or goal complexity.

Check health plan guidelines to learn what criteria are associated with different dosage levels. The criteria are typically related to areas such as:

• • Critical time period to gain new skills or not
  • Rate of progress
  • Complexity of child’s needs
  • How often therapy plan needs to be adjusted
  • How often caregiver training is needed and/or home program needs to be adjusted

Make sure your documentation addresses those areas.

Here are a few additional things to keep in mind at the time of re-evaluation:

• • Compare baseline to current data (consider emphasizing raw scores, growth scale values, etc. if most appropriate)
  • Clearly document functional gains
  • Report goal progress/status

Interested in More Tips & Strategies?

Join Jennifer Lawson, OTR, MS for Pediatric Therapy Foundations courses such as:

• • Medical Necessity in Pediatric Assessment, Dosage & Goal Writing
  • Meaningful & Effective Goal Writing and Visit Note Documentation
  • The Therapy Journey for Children with Chronic or Progressive Conditions
  • and more!!!

Does your therapy team need a solid, comprehensive clinical orientation / pediatric foundations course package?

We’ve got you covered.

Check out the Knowledge Is Now Pediatric Therapy Foundations Clinical Orientation License!