Massachusetts bill (H 1070/S 1093) adds to the definition of “medically necessary services” and challenges the notion of who decides medical necessity. Medical necessity criteria sits at the center of case and claim determinations. Laws, policies, and procedures evolve through time and the various administrations both locally and nationally.
In the 1970s, as part of the extended managed care infrastructure, new external institutions for supervision of medical necessity, appropriateness, and quality of care were formed. Even after these many decades of use, medical necessity criteria present five issues that still cause grief and need attention for MNC success.
Medical Necessity and Levels of Care (LOC) criteria are interdependent sets of objective and evidence-based health guidelines used to standardize coverage determinations, promote evidence-based practices, and support a patient’s recovery and well-being. Being such, LOC application, documentation, and accuracy plays a pivotal role in care and reimbursement.
Medical Necessity | Edits There are few things more frustrating to a physician than a pile of Medical Necessity edits. Medical Necessity is the term we use in healthcare to describe care what is reasonable and appropriate for a patient based on evidence-based care standards. This has become something of a major bone of contention between payers and physicians, because, often times, physicians don’t understand why their clinical judgment is being brought into question.
What do ASAM®, LOCUS®, CALOCUS®, and InterQual® all have in common? They are all level of care assessment tools, each with a different perspective. Level of care isn’t a new concept, but has gained in popularity in recent years. A level of care is used to indicate a level of intensity or severity and determine in what type of facility specific care should be performed. It is used to make sure the patient receives the right care in the right facility at the right time.