Almost every physician in this country has heard this phrase, “denied as not meeting medical necessity for the service performed.” What does this mean? How does a practice document medical necessity? Not knowing the answer to these questions can greatly affect a rheumatology practice’s financial well-being.
The problem with meeting medical necessity is misunderstanding what it means and how it affects you and your patients. The CMS defines medical necessity as “services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the function of a malformed body member.”
Insurance Carriers’ Guidelines for Medical Necessity
It is critical that physicians document facts to support the medical necessity for a procedure or drug given to their patients. This can be achieved by documenting some of the following:
- Clinically based evidence: Many carriers require evidence supported by at least two clinical trials that reveals the safety and effectiveness of the procedure or drug. The clinical trials must be published in national or international peer-reviewed journals and cannot include publications by pharmaceutical companies.
- Diagnosis: The diagnosis will support the need for a procedure or drug. Many times, practices will have a charged denied because the diagnosis does not warrant the medical need for that service. For example, a chest X-ray will be covered for a diagnosis of a cough but may not be covered for a diagnosis of RA.
- Frequency: A procedure can also be deemed as not medically necessary, and therefore denied, if performed multiple times during an approved time period. For example, many carriers have a frequency requirement for knee injection with the drug Synvisc-One, requiring at least six months between injections.
Resources for Medical Necessity Guidelines
There are many resources available to learn about carriers’ guidelines for medical necessity. Guidelines are often listed under medical policy on the carriers’ websites. On the CMS website, medical policies are found under the local coverage determinations. Private carriers may have this information under utilization guidelines.
You can also find procedural articles on carrier websites. CMS articles can be found under the Medicare Learning Network articles section, and private carriers usually post articles under an article section or medical bulletins.
Most carriers have a list serve that you and staff can register for to receive medical policy updates. Both private and Medicare carriers publish articles on procedures that may include coding changes and frequency changes. Free webinars or audio conferences supplied by carriers are also a good resource.
