Medical necessity is a medical claims determination which encompasses outcomes which are justified as reasonable, necessary, and/or appropriate based on evidence-based clinical standards of care. Evidence-based medicine (EBM) aims to apply the best available evidence to clinical decision making. It seeks to assess both the of risks and benefits of treatments and diagnostic tests and assists clinicians in determining whether or not a treatment will do more harm than good.

From the CMS website, Medical review (clinical review) is the collection of information and clinical review of medical records by Medicare Contractors to ensure that payment is made only for services that meet all Medicare coverage, coding, and medical necessity requirements. Medical review activities are directed toward areas where data analysis, Comprehensive Error Rate Testing (CERT) and Office of Inspector General (OIG)/Government Accounting Office (GAO) findings as well as Recovery Audit Contractor (RAC) vulnerabilities indicate questionable billing patterns.

Goal of the Medical Review Program

The goal of the medical review program is to reduce payment error by identifying and addressing billing errors concerning coverage and coding made by providers. To achieve the goal of the medical review program, Medicare Contractors:

  • Proactively identify patterns of potential billing errors concerning Medicare coverage and coding made by providers through data analysis and evaluation of other information (e.g. complaints);
  • Review CERT data, RAC vulnerabilities and OIG/GAO reports;
  • Take action to prevent and/or address the identified error;
  •  Publish local medical review policy (called Local Coverage Determination-(LCD)) to provide guidance to the public and medical community about when items and services will be eligible for payment under the Medicare statute; and
  • Publish MLN (Medicare Learning Network) educational articles as they relate to the medical review process.


Physician Services

Physician services are completed by an independent review organization (IRO). The goal of the IRO is to provide a formal process to file an appeal when a Medicare case has been denied.  It provides a second review to determine whether or not medical necessity is met. Appeals are also called reconsiderations or redeterminations. The medical peer reviews the case again and issues a determination which may be one of the following: approved, denied, partially denied.


BHM Healthcare Solutions Physician Review Portal

BHM has a state of the art physician review portal which completely automates the physician review process. The portal does the following:

  1. Allows the client to enter the information electronically into the portal
  2. Generates an automatic email to BHM notifying a case has been added
  3. Allows BHM to assign the case to the appropriate physician for review
  4. Generates an automatic email to the physician reviewer notifying them a case has been assigned to him/her
  5. Allows the physician to make a determination as well as provide any supporting documentation
  6. Generates an automatic email to BHM as well as the client indicating the case has been completed

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