Finally, you’ll learn how to unlock the riddle of medical necessity to avoid denials and scrutiny by auditors.
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Medical necessity is the Rubik’s Cube of healthcare. And while the concept is used to determine if a patient’s care is a covered service, that simple explanation belies layers of confusion and contradiction making the term, “medical necessity,” in some cases, the license payers can use to deny claims. To avoid claim denials, takebacks and lost revenue you need to have all the pieces in perfect alignment. There’s another level, too, of medical necessity to consider — site of service. Also, there’s one more element to the puzzle: patient status. Just as there are lessons to be learned in solving the Rubik’s Cube, this upcoming webcast by Ronald Hirsch, MD, you will learn how to solve the troublesome riddle of medical necessity.
Adding to the confusion, there are hundreds of payers and therefore the potential for hundreds of different medical necessity rules. Denials may not always clearly state why a service was deemed not necessary- was it a lack of documentation or did the service truly not meet the guideline? It also takes cooperation of the providers to get adequate documentation to determine medical necessity. For Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) apply but LCDs only apply to the MAC jurisdiction and two patients in different states could have different standards applied to them. Layer, upon layer of confusion with multiple colors and corners to assemble correctly, little wonder medical necessity is a conundrum. Now, at last, there’s a solution to the confusion: register now to gain access to “Unlocking the Riddle of Medical Necessity.”
With hundreds of payers in the healthcare market places, there’s the potential for hundreds of different medical necessity rules which, if not understood, could contribute to denials and takebacks.
Those who will benefit most from this webcast include staff in denials and appeals, utilization review, revenue cycle, revenue integrity, case management and compliance, as well as chief financial officers, chief nursing officers, physicians and physician advisors.
Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI, FABQAURP is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays.
The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).
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