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. …show more content…
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 the concept of medical necessity for making decisions about claims payment. Medicare and private payers will not pay for services they consider unreasonable for, diagnosing patients, treating illness or injury. When choosing necessary level of care for any encounter, medical necessity trumps everything, including documentation of history, physical exam and medical decision-making. Also, meaning that even perfect documentation of these key components will not ensure protection if auditors find that medical necessity is not necessary.
A patient comes to a physician’s office complaining of intermittent chest pain. To address this patient’s concerns it would be medically necessary to take a comprehensive history. Each part of the patient’s history is relevant; past medical history, present illness, risk for any cardiovascular disease and social …show more content…
“Non-covered” vs. “not medically necessary” should not be used interchangeably because a service may be considered medically appropriate, but excluded from coverage.
Adding more complexity to the understanding of medical necessity in an article highlighting the issues around medical necessity, the author describes the inconsistencies in the interpretation of medical necessity and explains how little consistency exists amongst insurance plans in defining and interpreting medical necessity. The author included a study by the United States General Accounting Office, which described tremendous variability in the way claims were processed and denied. (Bergthold, 1995)
Another interesting article on this subject was published in the New England Journal of Medicine in which the authors suggest that the burden of proving should be on the insurer rather than the physician and that the insurer should be able to provide evidence that the care was against the generally accepted guidelines. (Rosenbaum,
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. …show more content…
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 the concept of medical necessity for making decisions about claims payment. Medicare and private payers will not pay for services they consider unreasonable for, diagnosing patients, treating illness or injury. When choosing necessary level of care for any encounter, medical necessity trumps everything, including documentation of history, physical exam and medical decision-making. Also, meaning that even perfect documentation of these key components will not ensure protection if auditors find that medical necessity is not necessary.
A patient comes to a physician’s office complaining of intermittent chest pain. To address this patient’s concerns it would be medically necessary to take a comprehensive history. Each part of the patient’s history is relevant; past medical history, present illness, risk for any cardiovascular disease and social …show more content…
“Non-covered” vs. “not medically necessary” should not be used interchangeably because a service may be considered medically appropriate, but excluded from coverage.
Adding more complexity to the understanding of medical necessity in an article highlighting the issues around medical necessity, the author describes the inconsistencies in the interpretation of medical necessity and explains how little consistency exists amongst insurance plans in defining and interpreting medical necessity. The author included a study by the United States General Accounting Office, which described tremendous variability in the way claims were processed and denied. (Bergthold, 1995)
Another interesting article on this subject was published in the New England Journal of Medicine in which the authors suggest that the burden of proving should be on the insurer rather than the physician and that the insurer should be able to provide evidence that the care was against the generally accepted guidelines. (Rosenbaum,