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The Necessity of Getting Medical Necessity Right

Medical necessity is one of the hardest things for both payers and providers to get right due to the complexity these policies usually require. However, medical necessity serves an important role in patient safety and fraud prevention, so it must be verified.

Medical necessity is a determination that a particular healthcare service, procedure, or treatment is appropriate, reasonable and necessary for the diagnosis or treatment of a patient’s medical condition.

For payers, getting it wrong can mean thousands, if not millions, of dollars wrongfully paid or wasted on downstream work associated with excess claim denials and recoupments. Getting it right means providers are reimbursed accurately the first time; patients receive the appropriate level of care and correct medications; and payers minimize overhead costs associated with claims review and rework.

To help payers get it right and be compliant with CMS National Coverage Determinations (NCD) and Local Coverage Determination (LCD) policies, MediQuant, a partner in the Source ecosystem, offers the full range of medical necessity edits, including:

  • Procedures and diagnosis codes
  • Add-on procedures
  • Primary and secondary LCDs
  • Covered and non-covered diagnosis codes
  • Denied codes
  • Frequency limitations
  • I/P restricted CPT/HCPCS
  • Effective dates
  • Commentary on rule changes with every update

Making Medical Necessity Easier for Source Customers

As a transformative payment integrity solution for payers, Source has developed partnerships with many different best-of-breed vendors, including MediQuant. As part of the Source ecosystem, MediQuant is able to leverage advanced APIs from Source to deliver pre-built integrations between the two systems. This not only eliminates the IT burden for payers who want to use both solutions, but it also creates a more seamless user experience. Plus, it’s easy to configure, as Source automatically indicates if/why a policy impacts a claim.

The result of Source + MediQuant?

Results include streamlined clinical policy maintenance, prior authorizations, coverage determination, and claims processing.

Payers are also able to minimize provider abrasion related to wrongful denials while also better managing utilization across all care settings, including hospitals, physician offices, labs, and imaging centers.

To learn more about how Source + MediQuant can help your health plan dramatically reduce denials due to improper or incomplete documentation of medical necessity, visit the Source third-party integrations page here.

About the Author

Carl works closely with healthcare payers and the intricacies of their data and IT ecosystems. His deep understanding of each payer’s unique needs helps to identify root-cause issues and solutions.

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