Medical Necessity And The Current Era Of Health Information Technology

1271 Words Oct 27th, 2015 6 Pages
In order to discuss medical necessity in the current era of health information technology, we must have a comprehensive knowledge and understanding of medical necessity. Most of this article focuses on explaining medical necessity and towards the end includes some thoughts on how medical necessity relates with health information technology.
The meaning of medical necessity is different for providers, physicians, courts, government/private insurers, or consumers. Medical necessity is used for managed care plans as a tool to deny or approve necessary care. From the government’s point of view, the Medicare/ Medicaid statutes authorize payment only for medically necessary care and impose criminal/civil for claims that are medically unnecessary. (Ongrod, 1999)
The United States legal doctrine defines medical necessity to activities, which may be justified as reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care.
From insurer’s point of view, Medicare will not cover services that are not necessary for diagnosis or treatment of illness to improve the functioning of a malformed body member. (SSA section 1862 (a) (1) (A))
As per the Medicare’s manual of claim processing, medical necessity criterion for payment in addition to the individual requirements of a CPT code. Billing a higher level of evaluation and management service is medically unnecessary or inappropriate when a lower level of service is warranted.
Medicare and private payers use…

Related Documents