FROM OUR PARTNERS: USING TECHNOLOGY TO ENSURE MEDICAL NECESSITY COMPLIANCE
By Jerry Kolosky, Product Marketing Manager for 3M Health Information Systems

Denied claims hit providers hard. When practices fail to met Medicare medical necessity requirements, they face a wide range of consequences.

Primary among these, of course, is lost revenue – taking the form of claims denied outright, payment delays, prolonged A/R cycles, reduced cash flow and line item rejections.

But the penalties for non-compliance with medical necessity rules go well beyond denied claims. Fraud investigations are common, and compliance is strictly monitored and enforced. This means that non-compliant providers face government action that may include potential audits, fines, penalties, operating under a corporate integrity agreement or even the revocation of the right to treat Medicare patients.

Maintaining Medicare compliance, however, represents a significant administrative and financial challenge for physician practices. Increasingly complex medical necessity regulations, combined with a lack of integrated processes and tools, make medical necessity review a difficult undertaking.

For instance, CMS establishes National Coverage Determinations (NCD) governing Medicare medical necessity compliance regulations throughout the country. Local carriers and fiscal intermediaries create additional policies known as Local Coverage Determinations (LCD) for regional coverage areas. A given practice can face up to 500,000 unique ICD-9 and CPT/HCPCS code pairs, all subject to policies that vary from state to state, and which can be updated quarterly, monthly or on an ad-hoc basis.

And the situation will only get worse as medical necessity restrictions are expected to grow only more complex.

Keeping up-to-date with these complicated and ever-changing rules is a monumental task. It is, nevertheless, vital that a practice do so. Medical necessity errors greatly increase compliance risk and have a significant impact on financial health. To help them address these challenges, practices are looking for comprehensive solutions that effectively check for medical necessity at key points in the revenue cycle.

Navicure and 3M have partnered to provide one such solution: 3M Medical Necessity Dictionaries – comprehensive tables of thousands of CPT/HCPCS procedure codes, as well as supporting ICD-9 diagnostic codes – are now available to Navicure users. This enables users to automatically validate medical necessity prior to claims submission, thus ensuring that claims contain accurate and consistent medical necessity documentation – at pre-service, the point of coding and post-service – to help minimize compliance risk and ensure prompt payment.

For more information about this new offering, please contact 877-Navicure.

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