Remember the days when getting a prosthetic device covered, only required submitting a few handwritten notes consisting of maybe a paragraph? Now it feels like getting even the simplest replacement socket covered requires a doctoral thesis. And forget about getting the newest technology covered without going to court. I have met many practitioners who are brilliant at patient care, and understanding what they need to provide to the patient. But, when I ask them to write out exactly what they are doing and why, they look at me like I have three heads. Writing a good justification letter can be a rather daunting task, especially when paying to keep the lights on may depend on it. Here are some tips on how to write an excellent justification letter that will ensure that your family will be able to eat next week.

  1. Ask a lot of Questions 

            One of the first and easiest steps to writing a good justification letter is simply learning about your patient by asking the correct questions. Here are some examples: What are your long and short term goals? What does a day in your life look like? What do you do at work? What are your specific tasks at work? What tasks CAN you accomplish at home? What can you NOT do at home? What can you NOT do at work? How many levels is your home? What can kind of floors do you have? Make sure to be as specific as possible and follow-up with the patient. For example do not just ask “How many kids do you have?” Follow up with  “How old are your kids” “What type of activities are your children involved in?”. Because having a 15 year old vs a 5 year old at home greatly affects the level of care/responsibilities that is required from the patient. 

            Sometimes patients are not forthcoming with information, because they do not understand why you knowing the mundane aspects of their life will make a difference in whether they get their microprocessor knee or not. It is okay to have an open conversation with the patient about why you need them to answer all of these questions in as much detail as possible. I personally begin my questions with a statement like “Okay, I am about to ask you a million questions so bare with me. But you know how crazy insurance can be sometimes, so we have to play their game”. Typically the patient laughs, and is on board to answer any crazy question I throw at them. 

  1. Construct a Well, Organized Argument

            When I write a justification letter, I always try to think more like a lawyer and less like a CPO. I am trying to persuade whoever is reading this letter, that this patient does not WANT this prosthetic device, but he absolutely NEEDS it. I use firm, definitive statements and never “I feel/think” statements. I am direct and to the point. Most of the people reading these letters have a million other letters to read, so make your argument clear and effective. In general, this is how I construct my argument. Pay careful attention to the details you put in parts A & B, because you will refer to them heavily in the rest of your letter. 

            A. Patient information and history (Subjective) – This is where I do a brief synopsis of the patients most basic subjective information including side of amputation, height, weight, gender, vocation, goals, prosthetic usage, etc. 

            B. Patient physical information (Objective) – General health, limb health, extremely brief ROM/MMT, any history of surgeries, pain, etc. (only put in things that are relevant to this patient getting this prosthetic – do not add things like patient had his tonsils removed in 6th grade).

            C. Issues and what you recommend – If they already have a prosthetic, then briefly summarize what the current issues are, and why the patient cannot achieve their goals/ADLs with their current system. Finish this section with a brief sentence or two on what you recommend for the patient.

            D. Dive into detail on what you recommend and why. This section tends to take two-three paragraphs to accomplish well. If it is a new product on the market, I do a general review of what this product is, and how it differs from a current similar and less expensive product already available. For example, if I am trying to get a CoApt system for an UE patient covered, the first thing an insurance company will think is, what is so wrong with a cheaper two-sight control? So I do not just explain the CoApt system, but I explain how it differs and is better for this particular patient, than a regular two-sight control. I generally break-down each “feature” of the particular product, and explain how this particular feature will benefit the patient. It is imperative to give specific examples at this time (We will discuss further in point 3).

            E. Not in all of my letters, but in some, I do add research articles in to my letter. It is important not to go into grueling detail about what the paper says. Just add a small (but very accurate) piece of information from the research article that is pertinent to your argument. For instance, getting a custom pectus brace covered. Several research articles that came out of Korea, talked about the importance of wearing the compression brace for greater than 6 months to significantly reduce the risk of re-occurrence. I would quote that article, and then use that article as justification for why the patient would need the brace to be custom (i.e. because the patient will need to wear for greater than 6 months). Only add research that is pertinent to your point. And remember to ALWAYS reference your resources. 

            E. I end my letter with a summarization of my entire letter. When I write this section, I keep in mind “If the person reading this was to only reading this paragraph, what are the most important points I should include?”. 

  1. Give Specific Examples 

            So you know how the C-leg works and all of its features! That is great. But what exactly will it do for THIS patient? Giving specific examples can sometimes make or break your justification letter. What exact part of this patient’s life will be affected if he does or does not have this particular feature that is available with this type of microprocessor knee. Why exactly does your patient need gesture control features for his upper extremity prosthetic? What activities does your patient do that he needs a foot that moves in more than just one plain? Referring back to all of those annoyingly detailed questions you asked at the beginning of your evaluation is of the upmost importance during this section. 

4. Keep it Simple Stupid 

            Understand the technology that you are needing to get covered, write about it in an educated manner, but do not use overly technical terms. The probability of a fellow CPO reading this justification letter at the insurance company is rather low. So use concise, clear, and understandable terms. Do not over complicate your arguments and points. 

5. Use Proper Grammar / Sentence Structure

            Having poor grammar/sentence structure is not only unprofessional, but also very distracting, and makes understanding your points much more difficult for the reader. Make sure to have someone review your letter prior to submitting it to the insurance company. Remember that this letter is not only a reflection of you, but also your company. 

  1. Use the Resources Around You

            Most manufacturers have resources readily available on their website. So use them. Furthermore, many manufacturers offer assistance in writing appeal letters. Some will write the appeal letter for you, and others will simply review it, to ensure all of the important stuff is there. Ask a more experienced practitioner, or even your admin staff who have more experience in specific insurance denials about important details that you may need to add. Do not be afraid to do some research online, read a few blogs posts, and ask questions to fellow colleagues. 

While writing a  justification letter can be scary and tedious, constructing a concise and well thought out letter can save you hours of fighting denials, and help you get paid in a more timely manner. Do not forget to gather your facts and state them in a clear manner. Argue your point with respect and intelligence, and do not forget to use proper grammar! I hope this blog helps you feel more confident in writing your future justification letters! Good Luck!