Deconstructing Medical Necessity from a Payer Perspective

Medical necessity is a major buzzword commonly referenced in the industry that means different things to different parties depending upon the context in which it is applied. What medical necessity means to a healthcare provider can be in stark contrast to how insurance payers define medical necessity. Medicare defines medical necessity based on the Social Security Act definition, “notwithstanding any other provision of this subchapter, no payment may be made under part A or part B for any expenses incurred for items or services which, except for items and services described in a succeeding subparagraph or additional preventive services… are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member… which are not reasonable and necessary 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 imperative that medical necessity determinations be carefully reviewed for this applicability to each unique patient’s circumstances and treatment. 

This session by industry expert, Toni Elhoms will take a deep dive into how payers define medical necessity and will review various guidelines and medical policies incorporated into payer coverage rules, unpack the utility of local coverage determinations (LCDs) and national coverage determinations (NCDs) in medical necessity determinations.

During the session Toni will also discuss the role of accepted standards of medical practice, identify avenues for challenging medical necessity with payers, and so much more.

Webinar Objectives

There is often a major disconnect between how insurance payers interpret and apply medical necessity rules and how healthcare providers and physicians determine what care/treatment is medically necessary. This unfortunate disconnect can have systemic consequences for healthcare organizations. In this session, we debunk the most common myths surrounding medical necessity and offer strategies and insights for challenging medical necessity denials and appeals with payers.

Webinar Agenda

• Understand what medical necessity means from both an insurance payer and healthcare provider’s perspectives.
• Recall how to locate relevant medical coverage policies, LCDs, and NCDs
• Recall the factors that lead to medical necessity determinations.
• Understand the workflows and roles affected by the 2024 Split/Shared Service Updates
• Recall best practice tips to proactively address medical necessity issues.

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