According to a February 2022 report, out of $3 trillion in total claims submitted by healthcare organizations, insurers denied $262 billion. More than half of those denials came from commercial health plans, with gaps in healthcare claims management (medical necessity) responsible for 2% of denied claims. All told, medical necessity denials cost health systems $2.5 billion yearly.
Healthcare.gov defines “medical necessity” (also known as “medically necessary”) as “health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.” If health systems bill for care that doesn’t fall within medical necessity criteria, they risk claim denials and a time-intensive appeals process—in other words, significant roadblocks to getting paid for the services rendered.
But what exactly are “accepted standards?” And how can providers confidently know they’re billing for qualifying services or supplies without manually pouring through billing manuals for every commercial health plan? With today’s medical necessity edits (MNEs) exceeding 20 million, healthcare organizations can’t manually navigate the regulatory environment for each claim.
Accounting for MNEs for a broad range of commercial insurances in addition to Medicare and state Medicaid MNEs (for states with published information), the Vitalware® by Health Catalyst medical necessity solution offers a comprehensive, timely, and accurate solution to ease the complexity of claims management. Health systems can thus capture the benefits of billing within medical necessity criteria and avoid lost compensation and revenue delays.
Billing within medical necessity standards via a healthcare claims management solution, helps healthcare organizations secure the following revenue cycle benefits:
The Vitalware solution features the following key differentiators to help health systems fully leverage the above healthcare claims management benefits:
Healthcare organizations can significantly increase the likelihood of receiving payment for services rendered when they bill for care and supplies that Medicare and commercial insurers accept as medically necessary. However, with countless illnesses, injuries, and conditions to track, providers need a healthcare claims management solution like Vitalware’s, that’s built into their revenue cycle process and automatically ensures billing falls within acceptable standards.
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