Q: A lot of the questions and answers I see in Coding Insights involve “medical necessity.” Who defines this? How does this directly impact payments?
Most contracts between a provider and a payer state somewhere that payment will be made to the providers for “covered and medically necessary service,” and define the term “medical necessity.” These are also often related to other limitations on payment.
Most physicians have a kinder version of necessity: Is a particular intervention capable of providing a medical benefit to a given patient at a given point in time?
The example contractual language below is what governs your payments:
“The PLAN reserves the right to determine whether in its judgment a service or supply is medically necessary. Medically Necessary Services are: a) consistent with the symptom or diagnosis and treatment of the condition, disease, ailment, or injury; and b) not primary for the convenience of the subscriber, his or her physician, or other provider; and c) not primarily custodial care. The PLAN shall not be obligated to pay for and the physician shall not charge subscriber for services denied by the PLAN as not being Medically Necessary.”
The fact that a physician has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular problem or injury does not mean that it is a medically necessary covered health service as defined in the covered person’s benefit contract.
Q: I hear a lot about note cloning. Is there an actual law or rule about this that can be enforced?