Deconstructing Medical Necessity from a Payer Perspective

Understanding Payer and Provider Perspectives for Optimal Compliance

Medical necessity is a term that holds different meanings for different parties in the healthcare industry. For healthcare providers, it is about the patient's clinical needs, while for insurance payers, it revolves around coverage policies and guidelines.

Medicare defines medical necessity as:

“No payment may be made under part A or part B for any expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member … or for the prevention of illness, and in the case of hospice care, which are not reasonable and necessary for the palliation or management of terminal illness.”

It is essential to understand these definitions and how they apply to each patient's unique circumstances. Join us for an in-depth webinar by industry expert speaker Toni Elhoms, CCS, CRC, CPC, AHIMA-Approved ICD10-CM/PCS Trainer, where she will explore payer definitions, guidelines, and policies, including Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs).

Webinar Objectives

This session aims to bridge the gap between healthcare providers' and payers' perspectives on medical necessity. Attendees will:

• Gain a comprehensive understanding of what medical necessity means to different parties in the healthcare system.
• Learn practical strategies to challenge medical necessity denials and improve the appeals process.
• Discover best practices to proactively address medical necessity issues and enhance workflow.
• Become adept at locating and utilizing relevant medical coverage policies, LCDs, and NCDs.

Webinar Agenda

• What Medical Necessity Means:
  • From an insurance payer’s perspective
  • From a healthcare provider’s perspective
• Coverage Policies:
  • Locating and understanding LCDs and NCDs
  • Key factors influencing medical necessity determinations
• Workflow and Roles:
  • Impact of medical necessity on various workflows and roles within healthcare organizations
• Proactive Best Practices:
  • Tips for addressing medical necessity issues before they arise

Webinar Highlights

• Define what medical necessity means from an insurance payer’s perspective
• Define what medical necessity means from a healthcare provider’s perspective
• Discuss the various factors that create the underlying disconnect between payers and providers as it pertains to medical necessity determinations
• Review relevant local coverage determinations that impact medical necessity determinations
• Review relevant national coverage determinations that impact medical necessity determinations
• Discuss relevant insurance payer medical coverage policies that impact medical necessity determinations
• Review how to locate relevant medical coverage policies, LCDs, and NCDs
• Discuss the role of accepted standards of medical practice in medical necessity determinations
• Identify strategies for challenging medical necessity denials and appeals with payers
• Discuss best practice tips for proactively addressing medical necessity issues that arise

Who Should Attend

• Medical Coding Specialists
• Medical Billing Specialists
• Medical Auditing Specialists
• Private Practice Physicians
• Managed Care Professionals
• Operations Leadership
• Practice Administrators
• Office Managers
• Compliance Officers/Committees  
• Chief Medical Officer