Why Medical Necessity Is Important

properly documented and can be billed to you in the correct manner. Also, another use for medical codes is to protect yourself from false

"Medical coding professionals provide a key step in the medical billing process. Every time a patient receives professional health care in a physician’s office, hospital outpatient facility or ambulatory surgical center (ASC), the provider must document the services provided. The medical coder will abstract the information from the documentation, assign the appropriate codes, and create a claim to be paid, whether by a commercial payer, the patient, or CMS." (Aapccom, 2015) It is very important that billing coders have a full understanding of how to properly use medical codes to prevent denial of claims submitted.

The patient is informed about their coverage and the amount of copayment they would have to pay.

“This article discusses how Medicare Carriers and Fiscal Intermediaries use coverage determinations to establish medical necessity. When the condition(s) of a patient are expected to not meet medical necessity requirements for a test, procedure, or service, the provider has the obligation under the

- Taking into account the patient physical, social, psychological and spiritual health allow for allow for a more competent and effective patient care.

Service users should be given sufficient information about any treatment they are offered so that they can make an informed decision about whether or not to take it.  Information should include the benefits and possible risks of the treatment, the likely duration of treatment and any financial costs. The service user should also be given information on alternatives to the treatment being offered.

There are required Medicaid services that the state Texas must provide in acute care services (Hegar). These consist of inpatient, outpatient, labs, x-rays, physician, medical and surgical services by a dentist, early and periodic screening, diagnostic and treatment

One in particular states, “The hospital is professionally and ethically responsible for providing care, treatment, and services within its capability and law and regulations (Showalter,2013).” Patients may not always have the funds to be treated when their insurance coverage is not available. It would be up to the facility to decide how they are going to continue care in these situations. They have policies on the destruction of medical records. Another policy includes they must comply with the standards of emergency care. Also, that patients have access to interpreter services to include the most common languages used in the healthcare facility. These standards of care are updated all of the time by healthcare experts, nurses, staff, to ensure the most updated

To conclude this report, there are four considerations of a legal and valid insurance contracts that patients may present at the provider’s office or clinic. The guide to understand and remember are as follows: (a) the patient or person insured must be a mentally competent adult and should not be under the influence of drugs or alcohol; (b) the insurance company must have a signed application and offer the policy to the patient, then the patient or person should accept the issuance of the policy without misrepresentation of facts on the application of the person being insured; (c) the services produced and sold or the exchange of value and the first premium payment should be submitted with the application considered must be presented together; and (d) there should be a legal purpose which is an insurable interest in the case of a person’s healthcare insurance policy. These are good guidelines to know and understand for the success of an administrative life cycle of a physician-based claim (CMS

Id. In order for providers to avoid costly claim denials, a risk management and compliance program should be in place and annual monitoring and auditing of internal controls needs to occur on a regular basis. This text will review the issues that medical providers face with coding and billing regulations, the consequences of improper billing and coding, and resolutions that will aid in the prevention of claims being denied.

Instructor Explanation: Student answers will vary but might include cost reduction, patient preference, physician preference, and insurance coverage provisions.

Health care procedures are completed based on the necessity of the procedure. Acute hospital care is covered according to the Canada Health Act. These services may include, diagnostic

The expected benefit of the recommended or requested health care service or treatment is not more likely to be beneficial to the claimant than any available standard health care service or treatment.

“You do not meet the coverage criteria as outlined in Geisinger Health Plan’s drug policy.

If there are an emergency, the physician is obligated to treat the patient, but they are not obligated to treat everyone. If the