Free Presentation on Medical Necessity Criteria

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What is a case review? A case review is a medical review in which the clinical care is cross checked against a specific set of standards, such as Medical Necessity Criteria.  A reviewer will look at a patients level of care, intensity of treatment, and other care specifications to ensure that the care that was ordered, or provided by a physician or healthcare organization was appropriate and necessary.  When referring to case reviews, there are generally two broad categories of reviews:

  1. Internal reviews- internal reviews are reviews conducted by the same organization that provided the care.  For instance, an organization may review a case if there are special circumstances or if treatment is out of the ordinary, or does not appear to meet Medical Necessity Criteria to ensure that the care was in line with organizational standards.  Internal reviews may be conducted by the organizations in house Physician Advisor Department, or may fall under the Utilization Management Department
  2. External reviews – external reviews are reviews conducted by an outside organization who was not part of the provision of care process.  External reviews are often conducted by an Independent Review Organization, or an organization which specializes in conducting non-biased reviews of medical care to ensure that the appropriate Medical Necessity Criteria was met.

The goals of an external review are:

  1. To provide reviews which are free from conflicts of interests
  2. Establish standard requirements and qualifications for physician reviewers
  3. Set reasonable time frames for both standard reviews as well as expedited reviews
  4. Provide fair, impartial, and independent medical reviews