As the tide continues to shift in healthcare, you might begin to realize that insurance companies don’t think like you do. You are feeling pressure as they look more closely at the care you are providing and whether or not it aligns with the patient’s functional abilities and their forecasted outcomes. And, that’s why it takes your entire team to ensure you provide the highest level of care to your patients while creating the documentation that will get you paid.
These days, very few tasks in any O&P facility are accomplished by a single individual. Healthcare in the current climate is a team effort: understanding and appropriately documenting medical necessity is no exception.
What is Medical Necessity?
Medical necessity is a term that, while frequently used in our profession, is often misunderstood. Medical necessity is a legal doctrine. Though this definition seems simple enough, the principles which underpin the concept can be complex. Medical necessity is found where insurance coverage decisions intersect with medical decisions. Of course, the hope is that coverage decisions and medical decisions remain independent, but as most of us know, it is not always that simple.
An individual’s insurance coverage is a contract between the plan manager and the beneficiary. Medical decisions are the result of the clinical decisions made by the provider after evaluating and discussing treatment options with the patient. Medical necessity enters the conversation once a decision is made for a medical care to be covered by insurance. At this point, any dispute will be resolved by ensuring that the care provided was reasonable and necessary. This is the essence of medical necessity. Medical necessity should not be influenced by the insurance coverage.
The complexity of medical necessity is not only owed to its definition. Medicare defines medical necessity as, “services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” If we were left to that definition alone, perhaps solving the riddle of medical necessity would be easier. However, there are additional considerations.
- One is determining the appropriate frequency of the provision of care.
- Another is that we don’t deal solely with Medicare. Private insurers may attach exclusions or riders to this definition. This means that we must understand medical necessity in general terms, abide by the regional local coverage determination, and also ensure we are fully informed regarding a private payor’s medical policies. That is a great deal of information to process.
So, What Can You Do To Ensure You Prove Medical Necessity?
The clinician plays a large role in determining medical necessity during each episode of care. While the administrative and billing team solve the puzzle on the payor side, the practitioner must provide a thorough evaluation of the patient.
- It is critical to establish that the care provided is consistent with the severity of the patient’s diagnosis and current functional status. The best way to do this is to establish the patient’s prior level of function, and then clearly define what has changed in the patient’s condition since the injury or illness. That disparity is the clinician’s reason to intervene.
- The clinician must also document that services provided are safe and effective according to best practice.
- Lastly, there should be a reasonable expectation that the patient’s functional ability will improve. If we objectively document the patient’s impairments and apply appropriate outcome measures, then demonstrating positive improvements is a relatively simple task.
Are you ready to take your clinical documentation to the next level? Do you want to learn the goals and outcomes approach to clinical notes that will help you reduce your denials?
Join us at OPIE Con, May 3-5, 2018, Tampa FL. Register Now!
Chris has been in the healthcare field for over 15 years with a master’s degree in physical therapy, specializing in lower extremity prosthetics. Her practice has included neurology, orthopedics, trauma /critical care, and burn care across multiple settings. Chris serves as a Clinical Consultant for OPIE Software and Clinical Professor at UCF.
Connect with Chris | LinkedIn |