ITEMS IN FPM ON TOPIC:
Documenting medical necessity
Getting insurer approval for treatment can take hours out of your week. Here are some ways to reduce the pain.
Fix these problems to increase your bottom line.
This article from an insurance medical director explains the workings of claims review and gives tips on how to get the best results on appeal of an adverse decision.
The author describes how medical necessity is defined, what you do when you have one definition and your contracted plans has others and how you deal with a denial on the grounds that the service wasn't medically necessary.
The author hopes to educate members on Medicare policy on concurrent care and how to establish the necessity of such. Written based on a January 2005 suggestion from the Commission on Health Care Services.
The article explains how physicians can better recognize when visits coded as 99213 in fact satisfy the requirements for coding 99214. The author's method involves focusing first on the medical decision-making component, which he says encapsulates the true essence of the patient-physician interaction.
The authors offer readers an action plan to use in reacting/responding to payers' accusations of incorrect coding.
This article provides readers with step-by-step instructions for checking their E/M coding distribution with national guidelines established in the Centers for Medicare and Medicaid Family Practice Profile.
The article explains what physicians can do to make wiser use of hospital resources, including limiting lengths of stay to what is clinically necessary and referring patients to alternate facilities when appropriate.
The article discusses conflicts between medical necessity (what patients need as well as what they want but don't need) and medical benefit (what their insurance policies cover and don't cover) and the problems this creates for family physicians and their patients. The article will include a handout for patients and strategies for physicians who find themselves stuck in the middle of these conflicts.