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How Can Your Practice Avoid Medical Necessity Denials?

July 17, 2017



../../images/articles/How Can Your Practice Avoid Medical Necessity Denials

As a medical practitioner backed by formal training and years of experience, it gets be annoying to face Medical Necessity denial at practice. Both fee-for-service systems and value based payment systems face equal threat of 'medical necessity.' These denials are a major threat to a healthy functioning revenue cycle as the cases where the appeal is denied, the claim will be a loss altogether.

According to the prescribed procedure the care providers are required to inform the insurance beneficiary by issuing an Advance Beneficiary Notice in case the services to be provided do not meet the medical necessity requirements i.e. fall under non-covered category. If the ABN is not issued, the patient can't be billed for this 'non-covered service' and the practitioner would eventually have to write-off the denied claim. Whether it is a mistake on the part of the care provider or another tactic of the insurance company to avoid paying the claims, it is always clever to be fortified with options to fight denials like the ones based on medical necessity clause:

Coverage Verification:

As a practice intends to ward off the threat of 'necessity denial' from the claims it is filing, a first important step is to ensure verification of all the documents before admission of patient. This helps in bringing out eligibility issues if any. Verification implies that you get to better assess coverage provided by insurer and avoid the high percentage of facing denials. Arrange a system where front office staff can initiate checking of coverage documents before you see your patient.

Coverage Verification:

As a practice intends to ward off the threat of 'necessity denial' from the claims it is filing, a first important step is to ensure verification of all the documents before admission of patient. This helps in bringing out eligibility issues if any. Verification implies that you get to better assess coverage provided by insurer and avoid the high percentage of facing denials. Arrange a system where front office staff can initiate checking of coverage documents before you see your patient.

Limit Registration Errors:

Sometimes simplest of clerical errors like insufficient documentation can result in medical necessity denials. Practices are most vulnerable to medical necessity denials when clinical staff is not well-informed about the requirements for medical necessity or if front office staff lacks the tools and resources to quickly and easily ensure whether a test or service meets these requirements. Use of technology and certain software can limit the cases of medical necessity denials. Hence, it should be a rule to document clearly the reason you provide each service. In cases when a service performed is an exception to the guidelines or common standard of practice, it especially needs to be documented in detail as to why it was provided.

Involve The Patient:

After you have ascertained that the insurance company is going to pay for the procedure, DME, or office visit, it's time to sit down with the patient. You need to explain to the patient as to why you are treating them using this method or that product as this will educate them. The most important feature is helping them understand how it is going to assist them with their medical issue. This way you have an advocate to help you fight your claim, if the need be.

Patients are often afraid that they will be billed by you if their insurance does not pay. Because you've already educated the patient about the procedure you can ask the patient to call the insurance company and ask why they are not paying the claim. The patient is a customer to the insurance company. The insurance company wants to keep that customer, and might change decisions to keep them happy.

Regular Overview of Claims Denials:

In order to decrease claims denials you need to study the data on your claims submissions. Recognize the patterns that occur like a higher percentage of necessity denials which stem from the same error. If you follow the rules and document the medically necessary services you provide to your patients, you need to be confident to challenge the payer's initial determination.

EHRs have been re-invented to also assist in showing medical necessity. They have drop-down boxes with choices of statements that are becoming required by insurance companies are provided. This helps avert the necessity denials.

 

Category : Best Billing and Coding Practices