How Your Practice Can Overcome a 'Medical Necessity' Denial

March 10, 2012

Are your claims being denied because they were not “medically necessary?” Here's what you can do.

I've seen many denials from various insurance companies and noticed the alarming trend of “not medically necessary.” What does this mean? Medicare defines it as: “Services or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice.” But what we know it to mean is that the insurance company is dragging their feet and simply doesn't want to pay your claims. Another delay tactic, like dropping claims and stating they cannot locate the patient in their systems, and just another way they make their millions in profits.

What can be done about it? Several things, actually, and it starts with your patient. Before you see your patient, is your front office staff checking to make sure the patient has insurance coverage and authorization for any procedure or office visit? You would be amazed at what insurance companies cover and what they don't. For example, last July I had a terrible cold and my ears wouldn't clear. My physician's nurse came in with this silly looking fan that you place under your nostril, and she gave me a dixie cup of water to drink while this fan was blowing air up my nose. It worked, sort of, and my ears eventually cleared. Aetna not only covered it but paid $91.27 to “inflate my middle ear canal.” However, two years ago on Christmas Eve, I slipped on some wet stairs and broke my right ankle. Aetna did not cover crutches, stating “not medically necessary.” Seriously.

Once you have confirmed that the insurance will pay your procedure, DME, or office visit, it's time to sit down with the patient. Explaining to the patient why you are treating them using this method or that product, will educate them. Helping them understand how it is going to assist them with their medical issue is key. Now, you have an advocate to help you fight your claim. Patients receive EOBs either in the mail or electronically. They see what is being paid and what is not. Some of them actually read these EOBs. They are afraid that they will be billed by you if their insurance does not pay (well, at least the patients who pay their bills are afraid of this).

Since you've already spent your due diligence time with the patient up-front you can ask the patient to call the insurance company and ask why they are not paying the claim. After all, you are billing the patient's insurance as a courtesy to the patient, not as a requirement by law. Asking your patients to get involved is very much a choice of yours, and should be utilized when it becomes necessary. The patient is a customer to the insurance company. The insurance company wants to keep that customer, and often change decisions to keep them happy.

EHRs are emerging with technology that also assist in showing medical necessity. Drop-down boxes with choices of statements that are becoming required by insurance companies are provided. The time spent with the patient is provided. All of the necessary documentation is there at your fingertips.

Having a strong billing company that follows up with such denials is also very important. They write many letters on a daily basis showing medical necessity. Be sure to ask the billing representative assigned to your clinic what their procedure is for dealing with such denials.

Arming yourself with options to fight denials like “not medically necessary,” will always pay off for your practice.

Next week, we will look at how to balance your payer mix to benefit your practice.

Find out more about P.J. Cloud-Moulds and our other Practice Notes bloggers.