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  • Several ophthalmologists, have recently been successful in appealing their removal from Medicare Advantage networks. The Academy has worked with these physicians to create tips to craft a strong appeal letter.

    Arguments for Appeal Letter

    Network Adequacy

    • Describe any access issues to other area ophthalmologists encountered by your patients.
    • Specify if you are the only subspecialist in your area.
      • Note unique services your practice provides.
    • Determine the portion of the local population that you serve.

    Discrimination against specialty and subspecialty care

    • Point out that the likelihood of performing an intervention such as surgery is far more likely given the large percentage of your patients that are specifically referred for that purpose.
    • Note that for some subspecialties of ophthalmology, patients tend to be elderly and often in poor health, resulting in increased costs for care.
    • If you are a subspecialist, ensure that your costs are being compared to those of similar subspecialists (opposed to ophthalmologists in general or MD/OD pools).
      • Frequently-used methodology “selects against” subspecialists and will inadvertently eliminate such providers from the network. Examples include high costs associated with injectable medications for AMD for retinal specialists, imaging for glaucoma specialists, and MRI scans for neuro-ophthalmologists.
    • Ensure that the insurer had sufficient data from your practice and reviewed an adequate number of cases to draw conclusions.

    Patient and Practice Hardships

    • Make note of any patients who have conditions that cannot be treated by other area physicians.
    • List any disruptions to scheduled appointments, especially surgeries scheduled and post-op follow-up appointments.
    • Specify the anticipated impact upon your practice as well as how many patients will be affected.

    Ask about any information the insurer is willing to provide regarding the specific reason(s) for termination. This information may assist in preparing the appeal letter.