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Avea Solutions Blog

Here's Why Medical Necessity is Essential

Feb 22, 2019 8:15:20 AM / by The Avea Solutions Team

The Avea Solutions Team

 Appealing For Medical Necessity Can Be Exhausting. Here's Why It's Essential.

In 2019 and beyond, treatment centers of excellence must do everything they can to ensure patients are receiving the care they need, while also verifying that it can be obtained properly and legally. And the best way to do that if the appropriate units of care are being denied? By appealing. 

Yes, doing so can be difficult, but it's the only way to legitimately prove medical necessity if a payer is denying the care you've requested. Appealing is also essential for creating accurate data that can be built upon going forward. Going through this process as many times as needed is the only way to enact real, lasting change within the industry. 

Here are three important factors that should be considered when thinking about appealing:

1. Accurate Data Collection 

The primary concern for most facilities is to ensure patients receive the treatment they need, every step of the way. Unfortunately, all too often insurance companies won't provide enough care units to start those in recovery off on the right foot. For example, a facility may think five units of detox are necessary when a patient is first admitted, but the payer will only provide three units, in addition to 10 units of PHP care to begin post-detox. In these instances, treatment centers will often provide the five care units of detox they believe the patient requires, regardless of the amount the insurance company actually granted. The center will then bill the two extra days of detox they provided to the lower level of care (in this case, PHP), which costs the payer less. 

While this dedication to care is admirable, one of the drawbacks of this practice is it creates the very data that makes payers believe they've approved the right amount in the first place. Many facilities blame insurance companies for not giving them the care units they need, but these same facilities are also providing them with faulty data that makes it appear, on paper, that they’re getting exactly what's needed to treat a patient. It’s a vicious cycle that can only be broken by tenaciously appealing for medical necessity upon denial.

2. Remain In Compliance 

Another problem to consider when engaging with this practice: how can facilities possibly build an integrated electronic health record when they’re basically committing insurance fraud? Because make no mistake, that’s what they’re doing in this situation. If addiction recovery treatment centers aren't providing the care they say they are, how will payers ever know what does or doesn’t really work?

Some treatment centers may argue they’re not committing fraud, because they’re providing higher levels of care at lower rates. They’re not gaining anything, so why should they be punished? Many facilities also don’t understand how these practices impact their backend. If these care centers realized how they're actually helping payers by basically saying they can get by with less, they would begin to see how they’ve been selling themselves short.

3. Ensure Proper Patient Care 

Eventually, a patient gets down to intensive out-patient (IOP). But here’s where the problems for those in recovery can really begin. By the time they enter IOP treatment, their overall benefits may now be exhausted because of the practices described above, and the chances of a relapse increases dramatically. Some facilities aren’t considering how this practice affects a patient’s IOP care once they’ve gone home. Again, the importance of appealing cannot be overstated, as it's the only way that benchmarks based on real patient data can be established. 

The payers are not going to advocate for this. It’s entirely up to treatment centers. Our industry will only improve if we unite in our use of best practices. In 2019, we have to hold insurance companies accountable; but more than that, we need to hold ourselves to a higher standard as well. For the health of our industry, but more importantly, for the patients who trust us with their care.




Further Reading:

-  3 Questions To Determine If A Billing Company's The Right Fit For You

3 Ways Electronic VOB & Eligibility Saves Money & Time By Finding The Right Fit

- Aspen Ridge & Avea: Sharing A Vision

- Why AveaOffice?


Topics: Insurance, Claims Management, Addiction Recovery