CMS officials advise hospitals to use certified coders who are up-to-date on current practice, to implement internal quality reviews of their own cases for billing accuracy and correct
medical necessity documentation, and to respond within the 45-day deadline.
Configuration can be completed in a matter of days for registration data validation and editing; eligibility verification; authorization checking and completion; financial screening;
medical necessity screening; patient payment responsibility calculation; and denials management reporting and account resolution.
The federal court found that, to promote its own bottom line, UBH denied claims based on internally developed
medical necessity criteria that were far more restrictive than generally accepted standards for behavioral health care.
Of that, 91.2 percent was due to missing documentation and only 0.3 percent was due to the beneficiary not meeting the
medical necessity requirements.
Lack of
medical necessity is a defense to an action to recover no-fault benefits, which an insurer may assert upon a timely denial, based either on a medical examination or a peer review report.
[E]xternal-review decisions are independent determinations of
medical necessity that do not supersede contractual definitions of
medical necessity, wrote Justice Natalie Hudson for the court.
A district court in Washington, DC, has held that alleging a laboratory's failure to independently verify the
medical necessity of tests ordered by treating physicians is sufficient to survive a Rule 12(b) challenge to a federal False Claims Act claim.
Contract terms that involve
medical necessity also can lead to frustration if not properly negotiated.
There was no
medical necessity for emergency cesarean delivery.