Revenue Cycle

Tip: Medical necessity checks help stamp out denials

Patient Financial Services Weekly Advisor, February 4, 2005

Denials for medical necessity are a major concern for many medical facilities. NorthEast Medical Center (NEMC)-a 477-bed nonprofit community hospital in Concord, NC-is no different.

However, as a result of teamwork and changes in policies relating to billing, denials at NEMC have decreased dramatically during the past several years.

Pam Farmer, CT, CHC, manager of Diagnostic Support Services, shares some tips:

We now have numerous "stop checks" throughout our process to ensure compliance with medical necessity. Examples include:

  • When tests are scheduled, our schedulers make sure the reason for the test passes medical necessity. If not, the scheduler informs the office that the patient will need to sign an ABN.
  • When patients come to our patient registration area, representatives check for medical necessity for ordered tests and have the patient sign an ABN, if applicable.
  • When patients arrive for presurgery interviews, any tests ordered by the anesthesiologist are checked for medical necessity and patients are asked to sign ABNs, if applicable.
  • Prior to scheduled dates for radiological exams, all orders are faxed to our radiology coding department where staff check for compliance with medical necessity. If the orders do not have sufficient data, queries are sent to the physicians.
  • When patients arrive at various departments (e.g., radiology, endoscopy, etc.), the arrival staff again check for medical necessity and obtain ABNs, as necessary.
  • When coding accounts, the coders in the diagnostic areas (e.g., cardiology, laboratory, radiology, etc.) check for sufficient documentation of medical necessity. Again, if the information is not present, queries are sent to the provider.

      • Recovery Auditor Report

    • Recovery Auditor Report

      The Recovery Auditor Report is a free biweekly e-newsletter of useful tips and strategies to get you prepared for the...

    • Medicare Update for CAHs

      Medicare Update for CAHs is a free bi-weekly ezxne that provides specialized information for our CAH (critical access...

    Most Popular

    Related Articles