Last we talked about the critical need for hospitals to have a medical necessity program in place to ensure they’re prepared for any regulatory change that’s coming down the pike next.
An effective medical necessity program needs to begin with Patient Access checking coverage, validating payor rules and Local Coverage Determination (LCD) changes. Lack of pre-authorization is the #1 Patient Access-related reason cited for claim denials. So, a successful medical necessity program should have tools that:
- Flag prior-authorization warnings
- Offer timely access to medical necessity requirements for most major U.S. payors
- Provide reports that help assist physicians in understanding payor requirements for proper documentation
- Provide guidance on relevant reimbursement data to support appropriate upfront collections
What do you think are the keys to a successful medical necessity program?