16 Jun What Does Medical Necessity Mean to Your Practice?
Every successful medical practice must stay abreast of regulations and rules that govern their area of expertise. This is not an easy task and usually requires the help of at least one qualified executive assistant. The administrative staff should implement a training program that includes a continuing education component.
These features will allow changes to be recognized and gradually merged into existing practices within the deadlines established by regulatory agencies. Medical care providers and their staff members are expected to know when systems or requirements change, and not being aware of a new policy will not exonerate the practice from any sanctions that result of incorrect processes.
The term ‘medical necessity’ means at least two very different things, depending on which side of the gurney a person is resting. Patients may believe that certain diagnostic tests and procedures are medically necessary to rule out possible diseases and to develop a proper diagnosis. Patients will also consider a second opinion medically necessary and expect to have these claims covered by or reimbursed by their insurance companies or government assisted insurance providers.
To medical care providers, ‘medical necessity’ means quite another thing. Physicians and medical billing professionals define the phrase according to a completely different standard. Government agencies and insurance companies will each have different parameter for what types of services are considered a medical necessity. In addition, the procedures may also vary by individual patients.
Many factors are taken into consideration on a case by case basis, but a commonly used insurance company guideline that is relayed to patients may include generic language to define the concepts by which they will agree to cover and make payment for health care services. They define a medical necessity as the appropriate evaluation and treatment of a condition, disease, ailment, or other injury.
In addition to the accepted healthcare services, insurance companies may also choose to specify the healthcare providers that are able to perform these services. Claims agents may restrict certain medical staff members, such as nurse practitioners, from performing a procedure or making a diagnosis. Also, they may deny payment based on these criteria.
The challenging part of sorting through the never ending literature and policies provided by insurance providers and government agencies is that these criteria are subject to change without notice. Of course, there is almost always advance notice, but unfortunately, the notices may not ignite an immediate change on the books of a medical provider.
When a subsequent claim is filed for a patient and it is denied, a copy of the policy change is generally sent with the notice of denial to pay claim. This notice then prompts the medical billing staff to make the necessary changes to accommodate the insurance company. Most major insurance providers offer a grace period for changes to be implemented and may still make full or partial payments for the first oversight by a specific healthcare provider.
Another challenge of the coverage determination is that they are typically made on a case by case basis. This makes it difficult for a primary care physician to accurately determine whether or not a specific service, procedure, or diagnostic test will ultimately be considered medically necessary by the insurer.
Being a sensitive subject for both patients and healthcare providers, the idea of defining and establishing what should be deemed as medically necessary has not yet reached a final consensus. In fact, this will probably not come anytime soon since each affected agency has a completely different perspective and profitable angle for making the determination to finally define the meaning of ‘medically necessary’.