Eventually, most of us will receive an insurance denial claiming that our chiropractic services were not “medically necessary.” Certainly, this is a frustrating experience. After all, who is more knowledgeable about our patients’ needs than we are? Most of us understand the concept of medical necessity and are aware that our services are reimbursable only when deemed medically necessary.
For Medicare, this means our chiropractic adjustments must be for “active treatment” correction of a subluxation and not for purposes of spinal “maintenance.”
But sometimes medical necessity is a grey area that is hard to completely understand. The dilemma is due to several factors, primarily due to the fact that there are almost as many definitions of medical necessity as there are insurance carriers, laws and courts to interpret them. Unfortunately, the consequence of failing to meet medical necessity is black and white: denials.
And in 2015, we have an additional challenge coming our way: navigating medical necessity in the wake of ICD-10.
First, the Bad News
So, let’s take a detailed look at exactly what Medical Necessity is with the goal of reducing denials through better understanding.
According to Medicare, medical necessity involves the “diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”
While that sounds like a nice tangible definition, consider that Medicare has the power under the Social Security Act to determine if the method of treating a patient in the particular case is reasonable and necessary on a case-by-case basis. Worse yet, even if a service is reasonable and necessary, coverage may be limited if the service is provided more frequently than allowed under a national coverage policy, a local medical policy or a clinically accepted standard of practice. Unfortunately, this type of double speak is also readily apparent within the typical third party insurance contracts as well, apart from Medicare.
In plain English, this means is that even though you may have met medical necessity criteria according to some standards, a local medical policy (such as one adopted by your carrier or even your contract) could actually give power to the entity to determine that you have not met all of their standards for medical necessity.
More bad news.
Claims for services which are not medically necessary will be denied, but not getting paid isn’t the only risk. If Medicare or other payors determine that services were medically unnecessary after payment has already been made, they treat it as an overpayment and demand that the money be refunded, with interest. Moreover, if a pattern of such claims can be shown and the physician knows or should know that the services are not medically necessary, you (the lucky chiropractor) may face large fines, exclusion from provider panels, and criminal prosecution.
The “Emotions” of Medical Necessity
When considering Medical Necessity, these two words are certain to arouse strong emotions from most chiropractors.
For some, it is like an elusive murderer on the loose, ready to strike you down when you least expect it. You’ve heard the reports, seen the damage it has done to your community and fear its arrival in your clinic.
Others view Medical Necessity as a challenging summit only a few qualified climbers can actually surmount. You have heard about the requirements it takes; you almost know your efforts will fall short. But you prepare yourself and valiantly attempt to achieve it anyway.
Still others are left completely perplexed by the term. They are not even sure what Medical Necessity means. They don’t know where to begin or even where to focus attention to improve. They are confused and frustrated.
Then, there are those constantly looking for the ultimate Medical Necessity short-cut. The one size fits all. The stamp that will win all medical necessity approvals. Do “Step One, Step Two” and it’s a payday homerun for you!
All Players Are Disqualified
So let’s just start by disqualifying all players in the game above. I’ve seen a version of all of them in my clients and have talked to many DC’s who represent each. Here’s why:
Player #1 is likely to be paralyzed by fear and either will overcompensate by over-documenting for everything he does or will concede that he will be struck down soon and not bother trying.
Player #2 is definitely an over-documenter as well, but he burns out in the process of holding himself too rigidly in his attempts to produce the perfect documentation that will meet medical necessity.
Player #3 is woefully ignorant of any requirements of medical necessity and stabs around in the dark. He is as likely as a casino gambler to get the “winning” formula for medical necessity.
Player #4 is perhaps the most dangerous. After he finds the shortcut formula, he repeats it endlessly on all his patients. At first, he succeeds because he actually has met requirements. But because his requirements never change from patient to patient, his repeated submissions eventually show a pattern that gives him away. In time, he either fails to meet medical necessity and/or gets nailed in an audit.
What Medical Necessity is NOT.
In this discussion of how to best meet Medical Necessity, I will end Part One with a brief description of what NOT to do.
Medical necessity is not something achievable in a cookie-cutter pattern. Although this is one of the most common requests I get, there is no “stock” medical necessity SOAP note that you can just “plug and play” to meet medical necessity requirements. As above in Player #4, even if you could meet initial criteria with your super-replicator medical necessity machine, it would break down as you continued to treat the patient. As you progress, symptoms should change, objective findings should improve, goals change and essentially the necessity of the treatment will eventually change as well. So simply doing a nice “cut and paste” job will eventually fall short.
Medical Necessity is definitely NOT the same for all insurance carriers. As described above, medical necssity definitions may vary from payer to payer and on a case by case basis. And you have likely agreed to that fact within your contract. While this is the unfortunate reality of the game in which we play, we will discuss how the similarities of payer requirements so that you can achieve Medical Necessity in Part Two of this article (yep, you gotta wait!)
Medical Necessity is NOT Related to Your Writing Skills. Here’s a bit of good news! Certainly some DC’s write a book for every SOAP note visit in attempting to “make sure” Medical Necessity is achieved, but it is not necessary. Good documentation need not be lengthy, it just needs to cover all the necessary bases.
Stay Tuned for Part 2!
Now that we have touched upon the definition of Medical Necessity and discussed what Medical Necessity doesn’t look like, stay tuned for the next installment when I will lend some thoughts on how to achieve Medical Necessity in your daily documentation – more quickly and more easily than you’ve been doing.