tci Medicare Compliance & Reimbursement - 2019 Issue Q3

Reader Question: How Do Different Payers’ Define Medical Necessity?

Question:  Recently, we had a few claims denied that really surprised both our clinical and billing staff. The payers said the services rendered by one of our physicians were not “medically necessary.” I’m sure the provider thought the services were medically necessary — otherwise he wouldn’t have performed them. What definitions are payers using to determine whether a service or product is medically necessary? SuperCoder Subscriber Answer: According to the American Medical Association’s (AMA’s) 2011 report to the Institute of Medicine’s Committee on Determination of Essential Health Benefits, the AMA defines...

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