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.

Managed Care – Not New but our Healthcare Perspective Might Be

Managed care has been around for almost one hundred years, at least in theory. When placed up against fee-for-service payment models, however, it was a hard sell. Traditionally, the way that physicians were compensated for their services was a fairly straight-forward invoicing process: they would bill the patient (or later, the payer) for everything they did in terms of diagnosing or treating the patient. Everything.

5 Issues Associated With Medical Necessity

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.

By | 2017-04-02T13:28:32+00:00 August 26th, 2014|Physician Advisor/Peer Review, Services|1 Comment

Revenue Cycle Improvement Spotlight on CDI

Those of us who work in Health Information Management understand the value of good documentation -- and we have especially keen senses when it comes to recognizing excellent documentation when we see it. That being said, we also know when we’re seeing documentation that isn’t so great. And together with medical billers and coders, we’re always looking for ways to improve it.

By | 2017-04-02T13:28:41+00:00 March 25th, 2014|Clinical Operations Improvement, Financial, Services|Comments Off on Revenue Cycle Improvement Spotlight on CDI

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