Medical Necessity Project

Host: ProviderLAW Corporation

Welcome to the Medical Necessity Project.  This page lists the critical components for correcting and preventing medical necessity denials / recoupment in the arena of musculoskeletal care.  The more of these that you incorporate into your practice, the better you will fare.  Put another way, do each of these and you will do very well indeed!  Don't do them, and... well..., don't be surprised if you continue to lose a lot of money on the medical necessity front.  It's that simple. 

For more information regarding the Resources referenced on this page, feel free to contact ProviderLAW at staff@providerlaw.com.

ProviderLAW

Incorporate "Functional Radiology" Into Your Spine Care Practice

“If you are treating the spine, your primary and most powerful objective diagnostic procedure can be ‘functional radiology.’  At its core, functional radiology is what helps you, the provider, accurately and thoroughly understand and diagnose your patients' conditions -- where they currently are -- so you can more effectively get them where they want to go.  Even a GPS needs to know exactly where a person is to get that person to the desired location.  Without a GPS, think of how much time we as travelers spend 'lost.'  Become every patient's GPS.  Accurately and thoroughly diagnosing your patient's condition is the foundation for your course of care.  More than that, it is the basis for your CONFIDENCE, which is one of the main things patients are looking for in the first place.  Patients deserve nothing less than clinical excellence when it comes to their diagnosis and care.  We intend to see that they receive this.”   ~ Jeff Cronk, DC, CICE.  Click here to learn more....  

Get on Board With OutcomesAssessment.org   (Kim D. Christensen, DC, DACRB)

It's proven -- If you do even a reasonable job demonstrating functional improvement and/or relief of effects (e.g., pain), you can be very successful correcting and preventing medical necessity denials and recoupment.  For a sample appeal letter which illustrates this point, click here.  We at ProviderLAW are supporting OutcomesAssessment.org not only as a pioneering system for documenting functional improvement, but as setting a gold standard for both providers and  EMR / EHR developers alike.  EMR / EHR developers, we recommend that you contact OutcomesAssessment.org regarding possible integration. 

Know the Fundamental Laws of Medical Necessity

Text coming soon.

Master the 5-Step Assignment & Lien Protocol

Success in the medical necessity arena requires that you follow a defined Assignment & Lien Protocol.   You can do the greatest job in the world documenting your care, and in certain areas (e.g., accident cases), failure to sufficiently protect your bills will undermine your ability to get paid.  The 5-Step Assignment & Lien Protocol developed by ProviderLAW has been documented to solve 30+ collection problems in accident cases.  For more info, see ProviderLAW's Assignment & Lien Program.  Free 15-30 minute consults are available to those providers who wish to learn more.

The following sample appeal letter will illustrate just how important the Assignment & Lien Protocol is to getting paid (see yellow-highlighted text).

Gain Access to Powerful Notice & Appeal Forms

Unbeknownst to many providers, there are actually several key moments in time where you can communicate the medical necessity of  your care to payer, adjuster, claims handler and/or reviewer.  ProviderLAW has developed a powerful and simple "Notice & Appeal" system for leveraging these opportunities.  For example, you can notify the payer (1) at the time you send notice of your assignment & lien, (2) at the time you send your claims, (3) at the time you send your documentation, (4) at the time of the passing of the applicable prompt pay law, and/or (5) at the time of any denial or recoupment request.  These are not the only examples, but they are among the most important in the claims adjudication process.

For a sample appeal letter, click here. 

Have Someone Who Can Defend You in the Event of an Audit

Resources coming soon.