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Denial of Medical Bills Based on Medical Necessity

Hi, this is Ilana Sable and many of my clients want to know what is the best way to address any denial of your medical bills based on medical necessity? So, there are three key factors that you always have to consider when addressing these types of denials. The first is that you absolutely must maintain clear, well-established medical records for every patient encounter. So this means that everything from the initial visit through the follow up care and any ultimate courses or plans of treatment that you choose has to be well documented. So for instance, if you’re sending your patient for an expensive diagnostic test, which in many cases an insurance company is going to look into further before just paying the bill, you’re going to have to make sure the results of that test and any follow up care or treatment that you gave the patient are well documented in your medical records. Now, that should also include the results of that patients treatment whether it worked or not, for instance. Now, the second key is that your records should always comply with the 1995 and 1997 Evaluation and Management Guidelines. You need to know that almost all insurance companies use these guidelines when they review your records and they basically use a checklist to check off whether or not each point of your record is complying with the guidelines. So if you want to be paid for your medical bills, you need to make sure that your records comply with those guidelines. The third key is that you need to be familiar with your states managed care laws because when you are objecting to a denial or appealing a decision, in many cases the insurance companies can come back to you and say “well your records didn’t comply with rule XYZ and maintenance and so we’re going to deny.” You don’t to give the insurance company any additional reasons to deny your medical records so you need to be familiar with your individual states managed care laws and you need to make sure that your records are fully compliant with them.

I discuss all of these issues and more in my book “A Physician’s Guide” and I’d be happy to send you a complimentary copy. Also, if you have any questions, you can always call me by phone and I’d be happy to try and help you.

Ilana Sable

by Ilana Sable
New York and New Jersey Health Law Attorney

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