Medical Necessity: Its Importance in Billing and Reimbursement

  • Written by Ashley Mark
  • Tuesday 6th June 2023
Medical Necessity: Its Importance in Billing and Reimbursement VLMS Healthcare

Medical coding and billing is the primary factor affecting returns and revenue generation for any healthcare facility. There should be no affordability of medical coding and billing errors, as even a small mistake can lead to the rejection of a claim by the payer. These inaccuracies can lead to payment delays and cash flow and revenue cycle fluctuation. However, some medical coding can create legal challenges also.

Medical necessity is a critical concept in the healthcare industry and is significant for billing. In order to correctly diagnose a patient’s medical illness, a healthcare provider must understand if the procedure is necessary. We will explain the significance of medical necessity in healthcare billing and how it relates to patients and healthcare providers.

How to consider medical necessity

Healthcare professionals and physicians understand the need for medical treatment using medical standards, clinical practices, and other factors such as the patient’s medical history and current condition. Medical necessity assessment is the crucial phase in the healthcare billing process. It ensures that treatments and procedures are by the patient's medical condition and are not given irrelevantly.

Need for medical evidence.

A healthcare professional should always note the medical necessity of a treatment or operation in the patient’s medical record once they have made the evaluation. The relevancy of the service or procedure should be included in this paperwork. It should also contain any evidence that supports it.

Medical billing for healthcare needs the right documentation of medical necessity since it represents that the treatment was important and carried out correctly. Healthcare providers may encounter claim denials and other billing challenges if medical necessity needs to be appropriately established.

Billing for medical necessity

Healthcare providers can only initiate billing for medically necessary services. A claim being raised or other billing issues occurring because of billing for treatments that were not medically necessary can result in lost revenue and a down phase of revenue cycle management.

Denied claims handling

Healthcare providers may need to submit additional evidence to establish the medical need for the service if a claim has been rejected for the lack of medical necessity. It can be delayed in completion, resulting in high administrative fees and delayed reimbursements.

Stay connected with patients.

Medical practitioners should always inform patients about the need for any procedure, including high expenses. If a patient's insurance does not cover a process or operation that their healthcare physician found to be medically essential, they may be ready to pay the bill for the same.

When patients are informed about medical needs since starting, it helps control their expectations and sudden billing shocks. It also helps patients make on-time healthcare decisions and billing costs.

The bottom line

It is evident that medical necessity is an essential factor in the healthcare billing process, which also impacts billing and reimbursement. Healthcare practitioners can avoid denials and billing inaccuracies with improved revenue cycle management if they keep their patients informed about the medical procedure necessity. After all, medical necessity is an essential factor in the medical billing process. 

Medical necessity is also important for healthcare providers to effectively identify the complex healthcare billing process. With the right guidelines, clinical protocols, and the right documentation of medical necessity, healthcare providers can enhance their revenue cycle management and offer quality care to their patients.

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