Necessary Evil? 5 Medical Necessity Criteria Issues To Overcome

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.

By | 2017-04-02T13:27:55+00:00 February 28th, 2017|Physician Advisor/Peer Review, Services, Uncategorized|0 Comments

Levels Of Care Coordination

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.

Isolate Errors Impacting Payments

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.

By | 2017-04-02T13:28:02+00:00 August 29th, 2016|Physician Advisor/Peer Review|0 Comments

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