Payer denials, write-offs and claim rework can really hit a healthcare organization where it hurts the most – right in its bottom line.
Medical necessity is among the top-five reasons medical claims get denied, and those denials cost providers millions each year. In fact, medical necessity denials accounted for nearly 3 percent of all denials recorded in eSolutions’ TITAN performance insights tool, resulting in more than $8.9 billion in denied billed revenue since TITAN launched in 2011.
Medical necessity denials are also known as hard denials because they require an appeal to request reconsideration. Most hard denials are recoverable, but appeals are costly and usually require manual work from your follow-up team.
Manage Medical Necessity Validation through Automation
One way for healthcare organizations to avoid claim denials is to automate processes where they can. According to a July 2016 HIMSS Analytics survey, 31 percent of providers are still using manual claims denial management processes.
And that’s where Medical Necessity, a new product from eSolutions, comes in. Medical Necessity is a tool to help providers manage medical necessity-related denials, write-offs and claim rework by automating medical necessity checks and creating an Advance Beneficiary Notice of Noncoverage (ABN) when it’s required.
Medicare doesn’t cover services or supplies that aren’t deemed medically necessary; however, that doesn’t stop Medicare beneficiaries from requesting services deemed medically unnecessary or unreasonable. So providers must check whether a service meets medical necessity requirements before or during the patient’s appointment. If the service doesn’t meet Medicare’s medical necessity requirements, providers are required to notify beneficiaries by issuing an ABN for the non-covered service. The ABN should be provided to the patient before treatment to inform him or her that the service may not be covered by Medicare. If the ABN isn’t issued prior to the service, then the provider cannot bill the patient and any claim billed to Medicare for that service will be denied.
Checking to see if a service is medically necessary and sending an ABN is not a fun process. In fact, it’s a highly manual process. But if providers don’t check or don’t have a way to validate medically necessary procedures before providing care, they surely will face costly denials, write-offs, extra paperwork and patient dissatisfaction.
Mitigate Medical Necessity Denials with eSolutions
When a medically necessary request is initiated using Medical Necessity, a patient’s demographic information coupled with diagnosis and procedure details are used to check for medical necessity. If the service is deemed medically unnecessary according to Medicare’s guidelines, the product flags those services for the patient. If Medical Necessity cannot find coverage of the service by Medicare, it will automatically generate an ABN.
By incorporating Medical Necessity into your scheduling workflow, your front-office staff can streamline the medical necessity verification process. The product’s straightforward, intuitive interface makes it easy to initiate a medical necessity check on demand and it also stores historical information.
With Medical Necessity, you also can:
- Save time using workflow automation
- Eliminate potential of human error
- Alert patients to self-pay requirements before delivering care
- Store historical data in case of an audit
- Receive real-time policy data
- Prevent denials and write-offs
- Improve cash flow
- Look up a policy to handle an appeal
Don’t let medical necessity denials lay claim to any more of your budget or resources.Learn more about Medical Necessity today