In Order to avoid the denial claims there are some major repeated errors taken places.

Following Reasons:

• CLAIMS WITH MISSING INFORMATION
• CLAIMS NOT FILED ON TIME
• NON-SPECIFIC CLAIMS
• ILLEGIBLE CLAIMS
• CLAIMS BELOW PAYER STANDARDS

Payers use specific criteria to determine whether or not services provided to patients are medically necessary. Treatments, prescriptions, or procedures that do not meet the criteria for being medically necessary are typically not reimbursed by payers. Here’s a closer look at what your practice should be aware of.

Cigna provides a good definition of medical necessity. Their definition refers to services provided to patients by physicians using clinical judgment, and those services must be for diagnosing, treating, or evaluating a disease, injury, illness, or the symptoms of those problems. Cigna also states that services should be clinically appropriate in terms of location, extent, duration, and frequency.

Understanding Medical Treatment and Medical Necessity:

CMS allows Medicare Administrative Contractors (MACs) to determine whether services provided to Medicare beneficiaries are medically necessary. Original Medicare is assisted by 12 Medicare Part A and B MACs (Medicare Parts A and B). In addition to processing Medicare Part A and Part B claims, four of these MACs also process home health and hospice claims. There are four MACs specialized to durable medical equipment (DME).

MACs use the following criteria to determine whether services or items are medically necessary:

• It is not an investigational or experimental study.
• It is both effective and safe.
• When ordered and delivered by qualified personnel, it is appropriate.
• Provided in accordance with accepted medical practice standards.
• Provides for a patient’s medical needs in a setting appropriate to the condition and the patient’s medical needs.

Medical Necessity is driven by Diagnosis One of the key criteria driving medical necessity, from the payer’s perspective, is a patient’s diagnosis. The complexity of your medicaldecision-making may be a reliable substitute for the broadly defined idea of medical necessity, as it is based on the number and form of clinical difficulties as well as the risk to the patient.

Medical necessity is determined by providers using evidence-based medical data. The information could be used to request additional testing to diagnose a condition or to order additional procedures to treat that condition.

Clinical conditions and diagnosis codes are used by payers to determine medical necessity. When preapprovals are required, the procedure to be performed as well as the patient’s diagnosis must be submitted. Providers must also explain the severity of the patient’s diagnosis, any previous diagnostic studies or interventions, and the risk of not performing the ordered procedure.

Providers, billers, and coders must all be on the same page when it comes to medical necessity. WS specializes in medical billing and coding, assisting practices like yours in avoiding claim denials. If you’re worried about denials or want to increase your practice revenue, contact WWS today to find out how we can help.

What is Medical Necessity?

The first thing you should familiarize yourself with is what criteria payors use to determine medical necessity. Medicare defines medical necessity as “Health care services or supplies needed to diagnose or treat an illness or injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”

To make this determination, claim adjusters should consider the following:

1.  Are the services based on credible, scientific evidence recognized by the medical community?
2.  Are the services clinically appropriate regarding type, frequency, and duration?
3.  Is the service effective for the illness it is treating and not more costly than an alternative service?

This criterion is subjective, and even if the treatment is pre-authorized, the insurance claim can still deny. This is why it is critical to keep thorough clinical notes and record of the patient’s experience throughout his or her time at the facility.

How to Appeal?

Before, you write an appeal letter, gather all of the information you have on the client. Review, the diagnosis, the treatment plan and authorization number that you agreed upon with the case manager, and any clinical notes you have during treatment.

Utilization Review

Utilization reviews bridge the gap between providers, payors and patients. They help ensure that the patient receives the appropriate level of care and that the insurance company will reimburse the provider for their care. Proper case management is critical to insurance reimbursement. This means comprehensive intake assessments, knowledge of the patient’s past and current mental state, and timely follow-up calls to extend treatment, if necessary.

Here are the 4 things you should know before calling for a Prior Authorization:

• Call in the case within 24 hours of admission.
• Gather all of the relevant medical necessity documentation during the intake assessment.
• Monitor the client’s progress and if they need more treatment, call in the request days in advance.
• Stay organized. Keep a record of details and any critical information from the case manager.

Familiarize yourself with the appeal process for the insurance company that you are submitting the appeal too. Similarly, you will also benefit from reviewing the patient’s specific policy, verifying there are not any written provisions that you may have missed during the VOB.

Writing the Appeal

Once you are familiar with the appeal process gather all of the information to support your case, so that you are almost ready to write an appeal. Your letter should be clear and concise, citing specific, evidence-based reasoning as to why the insurer should reconsider the claim.

At the top of the letter, include the client’s name, policy identification number, and the claim number that you are appealing. List the name of your facility and the NPI or Tax ID number. Attach any clinical notes and send the appeal using certified mail, fax or per the insurer’s guidelines.

Understanding medical necessity is an important part of medical billing because it is why an insurance company actually pays for a claim.

Stay connected with us to learn more about Medical Necessity to reverse a denied claims or Email me at support@wonderws.com