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Samples in periodicals archive:
It is estimated that between 15-20 percent of the specialty drugs costs are due to health plans' inability to make medical necessity determinations.
In general, the following standards apply: * Once the insurer is provided with the information needed to make a medical necessity determination, the insurer must convey the determination to the hospital verbally or by fax within 24 hours or the next business day.
A medical necessity determination involves a judgment as to whether a plan should reimburse a covered and established treatment or service for a particular patient (Glassman, Model, Kahan, Jacobson, & Peabody, 1997).
Accurate and appropriate billing and documentation regarding medical necessity determinations have the potential to help hospital customers that have seen a recent increase in observation stays realize a projected average increase in revenue of nearly $5 million per year.
Counsel said that this latest settlement was yet another major development in their ongoing fight against insurers' alleged wrongful practices relating to medical necessity determinations and reimbursement for services provided to patients.
A clear definition of covered services and of the responsibility for making medical necessity determinations can minimize the risk of negligence and possibly provide an affirmative defense against a negligence claim.
Accurate and appropriate billing and documentation regarding medical necessity determinations have the potential to increase revenue for some hospitals by nearly $5 million per year per hospital1.
Inpatient review has caused significant adjustments among insurers' claims operations because of the necessity to add input into medical necessity determinations and to keep track of benefit plan authorization requirements.