I know several colleagues who, like me, trained to be doctors but they later pivoted to take on largely administrative roles working for health plans. Many have a central role in adjudicating what the ...

The significant cost in dollars, staff and time of claim denials makes medical necessity errors very risky for hospitals. Irene Barron, nTelagent COO and product management officer, explains how ...

If you have a bacterial infection, you need to take antibiotics. If health care providers need to determine that you have a broken bone, you’ll need to have an X-ray. Those are some examples of ...

Clinical and administrative staff at many organizations are struggling with the issue of what "medically necessary" really means - even those who have reviewed the Medicare Benefit Policy Manual (MBPM ...

Physician judgment and medical necessity increasingly are a focus of fraud and abuse enforcement actions, with statistical analysis of procedure volumes used to flag potential cases. Last week, the ...

There are many steps that inpatient hospital providers can take to avoid denial of their claims when submitting Medicare fee-for- service claims. The Centers for Medicare & Medicaid Services (CMS) ...

Following authorization from CMS on Aug. 6 to begin medical necessity reviews of 18 types of medical conditions, three Medicare recovery audit contractors have announced the start of such review, ...

A U.S. District Court in Connecticut recently issued an order that highlights the importance of understanding exactly what the term “medically necessary” means in an ERISA health plan. 1 This is ...

As recovery audit contractors set their sites on medical necessity of inpatient stays, hospitals enter a hazy area of compliance. RAC consultants say Medicare definitions of what constitutes inpatient ...

A focus on front-end revenue cycle efficiency can help to avoid costly medical necessity denials. Denials are at the top of mind for revenue cycle leaders, and it’s not uncommon for denials to come ...

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