What is Medical Necessity?
According to a RAC Auditor (RA), it is something that is justifiably reasonable and necessary according to evidence-based clinical standards of care.
According to who? Is this one-size-fits-all? How is this even possible?
If you are not scratching your head right now, then you must be the auditor applying your rigid rule to my client’s case.
Major Areas of Confusion
1. Cost vs. Outcome Reasonableness
Whether the cost of treatment is reasonable considering the patient’s chances of reaching a desired level of relief or functional improvement…
- This sounds like you are almost hedging on an investment. If you think you’re going to win, then make the investment? Not really.
- Let’s revisit the plan of care.
- If your plan of care mirrors a certain result in most cases, then this is where you want to be.
- Are you essentially over-treating a condition that can be cured or managed without the high-cost treatment that you have chosen?
- That is how you will want to treat this condition.
2. Mitigating Worse Outcomes
Whether the treatment will mitigate the patient’s risk of suffering an even worse outcome if the current condition is left untreated.
- Well, we have a serious problem here.
- Again, we cannot predict the outcome of a patient’s recovery, but what happens in most cases?
- You will want to approach this condition with as much research in your plan of care as possible.
Conclusion
If we can draw a conclusion from this article, here it is:
Did you use the lowest cost of medical treatment required to reasonably reach the desired result?
If you did, then your plan of care matches the cost and the outcome.
Frequently Asked Questions
What does “medical necessity” actually mean?
Medical necessity refers to healthcare services or treatments that are justified as reasonable, necessary, and appropriate based on clinical evidence and accepted medical standards. It’s not arbitrary, it must align with proven, evidence-based practices.
Is medical necessity determined the same way for every patient?
No, medical necessity is not a one-size-fits-all standard. Although guidelines exist, the evaluation should be tailored to each patient’s unique condition, treatment goals, and clinical presentation. Rigid application of generalized rules can lead to inappropriate judgments.
How is cost considered when determining medical necessity?
Cost is weighed against expected outcomes. If a lower-cost treatment can reasonably achieve the desired result, it’s considered preferable. However, cost alone doesn’t justify denying a treatment that is clinically more appropriate for the patient.
Can a treatment be necessary even if the outcome isn’t guaranteed?
Yes. While outcomes can’t be predicted with certainty, treatments may still be considered necessary if they are likely to prevent worse conditions or functional decline based on research and clinical precedent.
What is the role of the plan of care in proving medical necessity?
A solid plan of care that aligns with clinical evidence and expected outcomes strengthens the case for medical necessity. It should reflect the most effective approach for managing or resolving the patient’s condition without excessive or wasteful treatment.