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NW1005A: CONTINUING ED CHRONICLE™
UTILIZATION
REVIEW: PART 2A: DEFINING MEDICAL NECESSITY
10
CE hours
TAKE PART 2A NOW !
TAKE PART 2B NOW !
OBJECTIVES
1.
Discuss the differences between medical necessity and medical benefits
2. Discuss the themes related to denials that lead to lawsuits.
3. Discuss 5 different definitions of Medical Necessity.
OUTLINE
PART
1: MEDICAL NECESSITY IN PRIVATE HEALTH PLANS
I. |
Executive
Summary |
II. |
Introduction |
|
Research
Methods |
|
Structure
and Organization of the Review |
III. |
Medical
Necessity and the Published Literature |
IV. |
Industry
Practices in the Managed Care Industry |
|
Analysis
of the Structure of Medical Necessity Definitions |
|
Interviews
With Managed Care Officials on the Processes of Medical Necessity
Determinations |
|
Managed
Care Accreditation Organizations |
|
Judicial
Case Law, Official Investigations, and Legal Actions |
|
Judicial
Case Law |
|
Investigations
and Official Legal Actions |
|
New
York |
|
Maine |
|
Connecticut |
V. |
State
Law Regulation of Medical Necessity |
|
Laws
That Regulate the Content of Insurance Contracts |
|
Independent
Review Statutes |
VI. |
Relevant
Federal Laws Pertaining to Medical Necessity Reviews |
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ERISA |
|
Office
of Personnel Management Standards: FEHBP |
VII. |
Synthesis
and Implications |
VIII. |
References |
IX. |
Endnotes |
PART
2: Medical Necessity Determination in the Medicare Program:
Are the Interests of Beneficiaries With Chronic Conditions
Being Met?
Executive Summary
I. INTRODUCTION
II. National and Local Coverage Determinations
III.RESTORATION POTENTIAL
A. The Medicare Statute, Regulations, and Policy Manuals
B. What Happens in
Real Life
IV.ITEMS AND SERVICES COVERED UNDER MEDICARE PART A
A.
Skilled Nursing Facility Care
B. Home Health Services
V. ITEMS AND SERVICES COVERED UNDER MEDICARE PART B
A.
Utilization screens
B. Mental Health
Services
C. Durable Medical
Equipment
VI. CONCLUSION AND RECOMMENDATIONS
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