Explaining Wilson & Wickline Letters

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Explaining Wilson & Wickline Letters

As dental offices bill higher levels of restorative treatment it is becoming increasingly necessary to utilize appeals opportunities and peer to peer options to overturn unfavorable coverage decisions by medical carriers. A popular recommendation from consultants is to use Wilson & Wickline letters when appealing unfavorable decisions. It is important though to understand the landmarks these cases set so as not to use them inappropriately. Their overuse has rendered them no more effective in an appeal than the words “insurance commissioner” however, used properly with examples, they can be effective in supporting your argument for reimbursement.

The Wickline case approached the role of utilization review and the liability that those organizations bear when they approve or deny patient care. In 1986 Lois Wickline, a Medi-Cal beneficiary, sued the State of California for negligence in the denial of care which ultimately led to the amputation of her leg. Ms. Wickline had been admitted to the hospital for a vascular surgery and a 10-day approved hospital stay by Medi-Cal. During her treatment she developed complications which her primary attending felt merited an extended admission of eight additional days (after two unplanned additional surgeries). Medi-Cal denied the request for an extension and approved four days. Upon discharge Ms. Wickline developed a clot and infection in her leg which ended with the amputation of the limb. Her doctor made the argument at trial that had the extension been approved as he proposed he would have been able to identify the clot and infection immediately at onset and save Ms. Wickline’s leg. The court ruled in favor of Ms. Wickline with a judgment of half a million dollars – setting precedent for utilization review companies to be liable for negligence in denying requested treatment for patients. The decision was ultimately overturned on appeal with the crux of that issue being that none of Ms. Wickline’s physicians attempted to appeal the authorization denial.

The Wilson case happened four years later. This case also established the liability of utilization review companies. In that case the patient’s recommended in-patient hospitalization for depression and drug dependency. The recommended time frame was three to four weeks. Blue Cross Blue Shield denied the request for authorization and Mr. Wilson was forced to leave the hospital as he could not afford to privately pay for his treatment. Twenty days after the denial from Western Medical Review was processed Mr. Wilson committed suicide. His parents subsequently filed lawsuits against BCBS of Alabama (his carrier), BCBS of California (the local administrative plan), Western Medical Review and the claims reviewer at Western Medical Review that denied his authorization.

It is important to understand the appropriateness of introducing these two cases into your appeals and correspondence. Utilization review is commonly used in medical claims to control costs and ensure care is following a responsible pathway. As healthcare providers we have an obligation to fight for each patient’s healthcare needs regardless of decisions from insurance companies. Patients will not always get favorable outcomes from treatment, sometimes just by the natural order of things but sometimes by the irresponsible actions of those in charge of their care. Every healthcare provider has a duty to ensure that should the worst happen our patients have recourse to try to make themselves whole again. It is easy to understand denials when something is not a covered benefit or the proper preauthorization steps were not taken before treatment was rendered. However, when care is denied because it doesn’t meet medical necessity according to the plan, we need to take a closer look at what the reviewer or adjuster might have missed from the records. So the next time a consultant or sales rep suggests a “Wilson & Wickline” paragraph in your appeals letter feel comfortable in knowing that you know the appropriate time and place for quoting such cases.

Dental Billing Tips and News for Pros; Edition #132

3 Comments
  • Ryan Lemke DDS
    Posted at 17:27h, 06 February Reply

    What does a Wilson and Wickline paragraph look like in the paradigm of a dental clam appeal?

    • Jaycee Brown
      Posted at 19:03h, 07 February Reply

      Hi Dr. Lemke, great question. Stefanie Fario has an answer for you!
      “It is generally accepted by consultants and speakers that Wilson and Wickline is not helpful in dental carrier appeals. Some offices put a standard verbage that can be obtained from companies like Cerec however we don’t advise using any standard or canned verbages in your appeals. The Wilson and Wickline cases speak specifically to utilization review which is not a part of dental predetermination.”

  • Kathy Peterson
    Posted at 03:30h, 07 February Reply

    Thank you so much for the information. It’s definitely going to benefit me in writing my appeal letters.

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