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.
Understanding and determining medical necessity criteria challenges can be very complex for physicians, clinicians, coders, and billers.
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.
The medical reviews process is critical to healthcare ecosystem. The process helps protect against Medicare fraud and the many risks associated with atypical billing patterns and payments. The Social Security Act outlines very specific guidelines for reducing medical review error. Medicare contractors are used to help review data and medical records. Contractors ensure requirements for Part A and Part are in place and that claims data is reviewed for any errors. Through the collection of data and data analysis, medical reviews ensure that Medicare payments are not only met but also that they follow strict coverage, coding and medical necessity requirements.