Medical Necessity Criteria - PowerPoint Presentation

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Medical Necessity CriteriaAn Overview of Key Components

Presented by

BHM Healthcare SolutionsSlide2

Learning ObjectivesUpon completion of this presentation participants will have a thorough knowledge of Medical Necessity Criteria including emerging definitions

Participants will gain general knowledge of the role of managed care and efficacy of treatment in relation to MNC

Participants will understand the implementation of Mental Health Guidelines from multiple perspectives

Participants will be able to distinguish between Diagnostic Criteria and MNC, and how they effect determination of appropriate levels of careSlide3

What is Medical Necessity?“Medical Necessity” is the vehicle for specifying how broad or narrow insurance coverage will be.

“Medical Necessity like beauty, can often be a matter of taste or personal opinion and the idea of each his own does not work for medical necessity. The fact that a provider has prescribed recommended or approved medical care or services does not in and of itself make such care or services medical necessary or a covered service."Slide4

Defining Medical NecessityDefinitions of Medical Necessity vary according to the MCO, and payer but may include the following:

Intended to prevent, diagnose, correct, cure, alleviate, or preclude deterioration of a diagnosable condition

Care which is effective, appropriate, and necessary for treatment

Care that meets the basic health needs of the person

Treatment which is safe and effective according to a nationally recognized standard

Most appropriate and cost effective level of care

Service appropriate for symptoms, diagnosis and treatment of a particular disease or condition as defined under ICD-9 or DSM-IV

Service provided in accordance with generally accepted standards of professional practiceSlide5

Defining Medically Necessary Care

Most definitions of Medical Necessity incorporate principles of providing services which are

“Reasonable and Necessary”

Or “appropriate” in light of clinical standards of practice Slide6

Difficulties Using MNC

Differing definitions

Lack of biological indicator

Ambiguous diagnostic criteria

Reliance on

subjective

judgment

Lack of objectivity

Non public MNC decisions

Widely varying interpretation by providers

Decision makers don’t see the patient

Service limitations and care coverageSlide7

New Definitions Emerging

New definitions for MNC are emerging for the following reasons:

Culture of managed care

Shift from fee for service to managed system of care

New focus on the entire population; not a select fewSlide8

New Definitions Emerging Cont. New definitions must include an assessment of efficiency of care provided

Decisions based on MNC should be viewed as tools to help patients and payers make better informed decisions

Decisions based on MNC and cost effectiveness assist in defining relative not absolute thresholds

Decision rules must be able to incorporate individual patient risks, benefits and preferences

New definitions must allow for reasonable differences in physicians and patients beliefs about available treatmentsSlide9

Managed Care: The Good and The Bad The purpose

of managed

care is to serve

patient populations

managed

care is both a business and a humanitarian calling

These objectives can become distorted when business goals are couched in the language of medical necessityProblems arise due to the many, and varying ways to diagnose and treat mental illnessDiscrepancies can also arise as clinicians vary widely in their abilities and competenceSlide10

The Purpose of Managed CareManaged care strives to ensure that treatment is appropriate and cost-affective

Its purpose is to help you conceptualize, present, and document clinical care in a manner that greatly increases the likelihood that it will be approved

This is achieved through clinical review

Medical necessity criteria, diagnostic criteria, and clinical practice guidelines serve different purposes

These criteria are subject to different, yet equally defensible interpretations by different clinicians. This is to ensure a set of quality standards of care across all levels and in all areas.Slide11

Efficiency is Obtained When:Treatment is prescribed in the least restrictive environment

Treatment provided is cost efficient

When the intensity of service corresponds to severity of illness

MCO decision making thresholds used in medical necessity determinations are fair and consistently applied

The goal of behavioral care is to enhance the well being of patients through increased access to:Slide12

Implementation of Guidelines- Ethical Perspective

Guidelines were needed because allocating care which was once lenient has become strict

Cost of care is considered along with benefits and potential harm

There was concern that the managed care company was making a profit from enforcing greater practice efficiency

“The ethical issue therefore is not whether making a profit is right or wrong, it is whether the decision making thresholds used in making medical necessity determinations are fair and consistently applied.”

-William GlazerSlide13

Implementation of Mental Health GuidelinesMNC Criteria are guidelines used by utilization management staff to make payment determinations

MNC guide both providers and reviewers to the most appropriate level of care for a patient

MNC guidelines are not intended

to

replace prudent clinical judgment

MNC are not exhaustive and will not cover all situations

UM clinicians must make a distinction between a service being “beneficial” to the consumer’s health and a service being “essential” to the consumers healthSlide14

Implementation of Guidelines- ExceptionsSlide15

Diagnostic Criteria vs. Medical Necessity Criteria

Medical necessity criteria and diagnostic criteria are different

Diagnostic criteria focus on the signs and symptoms to make a specific diagnosis

Medical necessity criteria focus on the need for a particular level of careSlide16

Need For StandardizationThere are many ways to provide acceptable treatment for a patient

Clinicians vary widely in their abilities and competence

Medical necessity criteria, diagnostic criteria, and clinical practice guidelines serve different purposes

They are subject to different, yet equally defensible interpretations by different cliniciansSlide17

Appropriate Level of CareDetermining the appropriate level of care depends on the following three things:

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Evaluating Clinical Necessity for Continued CareIn evaluating clinical necessity for continued care three situations

may

existSlide19

Behavioral Health Management

Behavioral Health Management

Website:

www.BHMPC.com

Email:

results@bhmpc.com

Phone: 1-800-831-1171