Medical Necessity: Physicians Need to Prove It to Payers

As frustrating as this sounds, the insurance companies really are running the healthcare industry. Yes, I said it, out loud for all to hear.

Each insurance company has a definition of “medically necessary” (or medical necessity) and one may have a different set of standards than another. You don't really know what those are until you receive the denial for payment. The other area where they really tie your hands, whether in the treatment room or hospital, is what treatment codes they will authorize and which ones they won't - restricting you from providing the very best service to the patient.

I read an article the other day about how physicians and a patient are actually suing HealthNet for not paying a claim after they authorized it, stating "not medically necessary."

I, personally, have had experience with this type of situation back in 1998. I had obtained the proper authorization from Blue Cross to have a procedure done. Two days in the hospital followed and I ended up with a $35,000 bill from the hospital, physician, anethesioligst, labs, etc.

Blue Cross denied all of the claims because “it was not medically necessary” despite the due diligence of prior appointments stating that it was indeed necessary. Luckily, I was taught the difference between right and wrong, persistence, and how to respond when I feel like I'm being pushed around. I fought back. For two years.

I wrote letters to Blue Cross asking them to pay these bills. I “cc'd” all of my physicians, and they luckily stood behind me. After two years of receiving denial EOBs in the mail, I'd had enough. I sent a very thick notebook of all correspondence between myself and Blue Cross to the California Department of Insurance. Within two weeks, I received a letter from the department stating my claims had been closed and paid by Blue Cross. It took them two weeks. It took me two years and much persistence. Can you imagine how many people do not get the treatment they need and deserve because of an insurance company stating it is not medically necessary or worse, have to pay all of those claims themselves?

Insurance companies are also known for restricting what types of services you may provide a patient. It's filled in right there on the authorization. You can do “this,” but not “that.” You want to be paid, so you go along with it. How frustrating this must be for you and the patient!

So what can you do to make sure your patient is treated the way they need to be, and that you are still being paid for your service? Work with the insurance companies. Yes, I said that out loud, too.

Be diligent and when verifying benefits and asking for authorization, be sure to ask the rep if code XYZ is covered under the patient's plan, and if not, which one is equivalent is covered. If you need to write a letter of medical necessity, do it. Show them that by providing a specific treatment, it will help the patient in the long run, and cost the insurance company much less in cost.

Will allowing a patient physical therapy avoid surgery? Explain that in your letter. Can a series of treatments provide pain relief so that the patient no longer needs expensive medication? Explain that, too.

It's all about communication. Do your very best upfront to be as open and honest with the "why"s of the treatment the patient needs, and you are more likely to take back the control of who is really treating a patient. You.

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