AccessMyLibrary provides FREE access to over 30 million articles from top publications available through your library.
Create a link to this page
Copy and paste this link tag into your Web page or blog:
Health Plans, Others Defining 'Medical Necessity'.
WASHINGTON -- Managed care plans and accrediting bodies have started to incorporate elements of a Stanford (Calif.) University definition that seeks to achieve consensus in "medical necessity" decisions.
The state of Hawaii went so far as to include the definition in its new patient's rights law. "We haven't seen anything better. It's exactly what we wanted," said Chris Pablo, director of public government and community affairs at Kaiser Permanente in Honolulu.
Stanford's definition creates a framework for making treatment decisions and resolving conflicts that increasingly arise between health plans and doctors seeking treatment for patients, said Linda Bergthold, Ph.D., a research associate at Stanford's Center for Health Policy, who helped formulate the definition.
An ultimate goal is to replace a hodgepodge of vague and inconsistent definitions with a uniform national definition of "medical necessity."
The definition was conceived 2 years ago by a workshop of 20 members from the health and medical community, which convened in California as part of a Stanford research project on medical necessity decision making.
Workshop participants concluded that a model contractual definition of medical necessity should have five components: the decision-making authority; such as the health plan's medical director acting on the recommendation of the treating physician; the purpose of the health intervention; the scope of treatment to be provided; the evidence on which a decision could be based; and the use of cost-effectiveness to evaluate alternative treatments.
The evidence criterion would be used to assess existing as well as new interventions, and it explains which types of evidence would be required for each, Dr. Bergthold said.
- Maximize the likelihood of reimbursement when appealing managed care medical...
- Newspaper article from: Getting Paid in Behavioral Healthcare Small, Robert H. December 1, 2004 700+ words
...experience denials issued by managed care organizations (MCOs...two general categories: Medical necessity denials and administrative...the appeal process. A medical necessity denial is a determination...necessary based on the MCOs medical necessity criteria for the ...
- What's the appeal? Trying to control managed care medical necessity...
- Magazine article from: University of Pennsylvania Law Review Kesselheim, Aaron Seth January 1, 2001 700+ words
...insurance from a managed care organization...appeal their MCO's medical necessity determinations as...Bipartisan Consensus Managed Care Improvement Act of...definitions of "medical necessity" included in the...
- Consistent payment under managed care requires grasp of medical necessity.
- Newspaper article from: Getting Paid in Behavioral Healthcare Small, Robert H. November 1, 2003 700+ words
...can establish medical necessity. Providers...get paid for managed care patients...Second, medical necessity has multiple...services to managed care patients. The key features of medical necessity are as follows...
- Determining "medical necessity" in mental health practice.
- Magazine article from: The Hastings Center Report Sabin, James E. Daniels, Norman November 1, 1994 700+ words
...questions. The concept of "medical necessity" is currently the major...coverage by reference to "medical necessity," and with regard to managed care, the Institute of Medicine...first understand how "medical necessity" actually functions...
- Info-X to provide medical necessity content.
- Magazine article from: Managed Care Weekly November 17, 2003 700+ words
...Inc., to provide medical necessity content to its coding...new product, 3M Medical Necessity Software, is integrated...supporting these critical medical necessity solutions." This...was prepared by Managed Care Weekly Digest editors...
- CON CONGRESSDAILY White House Open To Talks On Medical Necessity Issue.
- Magazine article from: Congress Daily AM March 4, 1999 700+ words
...definition of "medical necessity." Insurance...that oppose managed care regulation...honed in on the medical necessity language as...which care is a medical necessity ought not simply...some sort of managed care bill could...
- DEFINING MEDICAL NECESSITY.
- Magazine article from: The Exceptional Parent Ireys, Henry T. Wehr, Elizabeth Cooke, Robert E. March 1, 2000 700+ words
...PROBLEM? In managed care plans, access...definitions of medical necessity may lead to...for Defining Medical Necessity 1. A covered...activities 2. The managed care organization...must determine medical necessity on the basis...
- NMHA decries lack of consumer focus, issues managed care standards.
- Newspaper article from: Alcoholism & Drug Abuse Weekly September 14, 1998 700+ words
...among states as managed care's influence...include vague medical-necessity definitions in managed care contracts and...cases, with the managed care organization...consumer. * Medical-necessity definitions and...
- Optimizing growth opportunities during the managed care revolution. (Managed...
- Magazine article from: Healthcare Financial Management DeMarco, Bill May 1, 2002 700+ words
...to develop innovative new managed care products and services to combat...insurance industry altogether. Managed care features exist within every...schedules and definitions of medical necessity just as managed care insurers have done. Consequently...
- Union outcry delays managed care plan for N.J. benefits.
- Newspaper article from: Alcoholism & Drug Abuse Weekly August 7, 2000 700+ words
...Concerned that managed care review would shut...centered around the medical-necessity criteria a managed care entity would use...relation to what medical necessity will entail and...arguing that a managed care contractor would...
Source: HighBeam Research, Health Plans, Others Defining 'Medical Necessity'.