Defining medical necessity
Fam Pract Manag. 2001 Sep;8(8):13.
To the Editor:
“Making Sense of Health Plan Denials” [June 2001, page 39] provided a helpful explanation of health plan denials. The definition of medical necessity has long been a contentious issue between practicing physicians and physicians who work for health plans or organizations responsible for utilization and quality management.
As physicians, we feel we rarely order things that aren’t medically necessary, although we know that much of the testing and treatment we do hasn’t been substantiated by evidence-based studies. In fact, many of us don’t really know what is medically necessary.
Having been on both sides of the aisle has helped me to better understand the complex issues involved but hasn’t brought forward any solution. I want patients to realize that although everything their physician suggests or orders may be medically reasonable and appropriate, it may not be considered medically necessary. However, I don’t want to create patient distrust of physicians’ recommendations.
When patients are denied payment for a physician-ordered service or treatment that they believe is medically necessary and the insurance company’s reason for the denial is that the service or treatment is not medically necessary, patients may seek recourse though the court system or legislative action. Although this may be gratifying to the patients, it carries the potential for even greater danger in that attorneys, judges, juries of lay people and government agencies would be making decisions on what is or isn’t medically necessary. In my opinion, this determination is best left to the medical community.
It troubles me that our profession has not tried to create a universal definition of medical necessity – one that is understood by patients, physicians and insurance companies alike and that can be applied in a fair and equitable fashion for the greater benefit of all concerned.
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