decisionhealth Newsletters, Part B News - 2017 Issue 7 (July)
Does ‘the patient’s wife insisted’ meet medical necessity?
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Article Overview
This article examines a medical necessity question that arises when a provider performs a service despite not recommending it. It explains the broader documentation and billing issues involved for Medicare and other insurance payers, with attention to liability notices and claim submission practices. The piece is aimed at coders, billers, compliance staff, and clinicians who need to understand how patient or family pressure can affect documentation and reimbursement risk.
Why This Topic Matters
Situations where treatment is provided at the request of a patient or family member can create documentation, coverage, and liability issues. Understanding the compliance implications helps practices decide how to document the encounter and evaluate whether payer payment may be affected.
What You Will Learn
- How patient- or family-driven treatment requests can affect medical necessity documentation
- Why liability notices may be relevant when a service is considered non-covered
- How claim-level notation may be discussed in relation to payer policy
- The compliance considerations that arise when a provider does not recommend a service
Who Should Read This
- Medical coders
- Medical billers
- Compliance personnel
- Physicians and other providers
- Practice managers
Modifiers Discussed
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