Medical Necessity
Medical necessity appeals shape healthcare. Uncontested medical necessity denials result in a subtle shift in treatment availability to the next patient because insurance carriers aim to consistently apply medical necessity limitations. Effective medical necessity appeals, on the other hand, bring to the carrier’s attention necessary variations in care, emerging efficacy issues, and situations that reveal flaws in the day-to-day clinical application of the carrier’s written criteria. For this reason, quality appeal review is critical to each of us. Appeal Solutions has detailed tools for improving medical necessity appeals.
Topic Areas for Medical Necessity:
Medical Necessity: An Ill-Defined Term
Medical necessity is a term which has different meaning to different health care participants. Understanding the carrier’s definition is helpful in drafting appeals. . . .more >>
What Goes Wrong With Medical Necessity Review
A number of shortcomings have been identified with medical necessity reviews. Be on the alert for the common procedural shortcomings which can indicate a poor medical necessity review process. . . .more >>
Medical Necessity Appeal Component 1: Summarize the Patient’s Care
The cornerstone of your appeal will be developing a compelling clinical argument for the care and referencing published clinical care guidelines. . . .more >>
Medical Necessity Appeal Component 2: Cite Regulatory and/or Compliance Information
Clinical arguments are often not sufficient to overturn an adverse determination. Your appeal must also cite potentially applicable regulatory and/or compliance issues in order to assure a quality review process. . . .more >>
Medical Necessity Appeal Component 3: Demand Disclosure of Payer’s Denial Basis
Payers rarely fulfill the obligation to fully disclose the basis of medical necessity denials. Reviewer's credentials, clinical review criteria and even date of development of clinical criteria should all be sought from the carrier to allow you to fully assess a denial's conformity to industry standards and regulations related to appeal review. . . .more >>
ERISA Medical Necessity Decisions
ERISA, the federal law which governs most employer-sponsored group health plans, has a number of protections directly related to appeal review. Among the most important to medical necessity appeals, ERISA requires expert review of any denial involving medical judgment. Unfortunately, while carriers often extend expert review to patient appeals, provider appeals often do not automatically garner a high quality, expert review process. . . .more >>
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