Central Issues surrounding Medical Necessity determination
Venkat Davuluri, MD, MMM, FACHE, CPHQ
Senior Medical Director at PA HEALTH & WELLNESS, INC.
With the backlash against managed care, medical necessity has become the focus of increased importance. Medical Necessity decisions generally involve authorizing treatment for an individual patient. They are different from coverage decisions. Both Medical necessity and coverage determination require medical judgment, and thus both clinical factors and payment considerations play a role.?
Some of the central issues surrounding Medical Necessity determination are:?(1) Who makes medical necessity decisions? (2) What are the variations in process and contractual definitions of medical necessity? (3) Can more information and better communication improve the process for consumers and providers? (4) What role should legislation and regulation play in promoting best practices and reducing unacceptable variation??
Ref:?Sara J. Singer and Linda A. Bergthold Prospects For Improved Decision Making About Medical Necessity?Health Affairs, 20, no.1 (2001):200-206?
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4 个月Great share, Venkat!