Medical necessity is a major buzzword commonly referenced in the industry that means different things to different parties depending upon the context in which it is applied. What medical necessity means to a healthcare provider can be in stark contrast to how insurance payers define medical necessity.
Medicare defines medical necessity based on the Social Security Act definition, “notwithstanding any other provision of this subchapter, no payment may be made under part A or part B for any expenses incurred for items or services which, except for items and services described in a succeeding subparagraph or additional preventive services … are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member … which are not reasonable and necessary for the prevention of illness, and in the case of hospice care, which are not reasonable and necessary for the palliation or management of terminal illness.”
It is imperative that medical necessity determinations be carefully reviewed for this applicability to each unique patient’s circumstances and treatment. In today’s webinar, we take a deep dive into how payers define medical necessity, discuss various guidelines and medical policies incorporated into payer coverage rules, unpack the utility of local coverage determinations (LCDs) and national coverage determinations (NCDs) in medical necessity determinations, discuss the role of accepted standards of medical practice, identify avenues for challenging medical necessity with payers, and so much more.
Toni Elhoms is an internationally known speaker and recognized subject matter expert on medical coding, reimbursement, compliance, and revenue cycle management. She is the Founder and CEO of Alpha Coding Experts, LLC (ACE). She holds multiple credentials with the American Health Information Management Association (AHIMA) and the American Academy of Professional Coders (AAPC). Ms. Elhoms’ expertise extends to both inpatient and outpatient coding, compliance, billing, and reimbursement. Ms. Elhoms serves as ACE’s Senior Consultant and conducts training and educational seminars across the country on a variety of topics including, but not limited to, Medical Coding, Medical Billing, Practice Management, Managed Care, Revenue Cycle Management, Revenue Maximization, Regulatory Compliance, etc.