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 ...

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 ...

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 ...

In Ghazarian v. Magellan Health (No. G057113, filed 8/7/20), a California appeals court reversed summary judgment that had been granted for a health plan insurer in a bad faith and unfair business ...

The non-profit organization Cost of Care has launched a new project designed to teach medical students and physicians about medical necessity, according to a news release. Funded with a grant from 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) ...

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Medicare limits coverage to treatments, services, and supplies deemed medically necessary. If Medicare does not consider a service medically necessary, it will typically not cover it. Medicare covers ...

In addition to setting forth requirements regarding the general use of AI in the claims process, SB 1120’s focal point is a provision in the bill stating that a determination of medical necessity may ...