Medical Necessity Essay

1271 Words 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.
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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
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These systems can be extremely expensive and due to the growing demands of documentation with the electronic health records, physicians’ remain apprehensive about not only the advantages of such a comprehensive system but also about whether payers will pay them more if they make the investment in such a system. In addition, most patients’ are still not fully aware and ready to use the available technology and therefore, currently not in a position to demand an investment of this magnitude from their healthcare providers. Instead, ease of access to healthcare and the records, along with a reliable and comforting physician-patient relationship remains of greater

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