Medical Necessity Denials

Managed care organizations and other healthcare products routinely employ utilization management programs. Payers spin these programs as efforts simply designed to ensure quality of care, but in fact, these programs are used to reduce the payer’s cost, thereby drastically reducing reimbursement to providers. Insurance companies are inherently designed to maximize profits and minimize benefits; utilization management is a prime example of how benefits are minimized. These programs identify and target expensive treatments to attempt to deny coverage whenever possible.

Utilization review programs attack the medical necessity of prescribed medical care and permit payers to interfere in the doctor-patient relationship. Through these programs, insurance companies undermine the medical judgment of treating physicians. The result is often uncompensated care.

Providers routinely satisfy their contractually-required administrative burdens by attempting to obtain pre-authorization for services, only to be informed their prescribed medical treatments are not medically necessary.  Or, when pre-authorization is requested, they are told no pre-cert is necessary, only later to be denied for medical necessity. 

When a patient arrives for an unscheduled event, whether via the provider’s emergency department or as a direct admit by a treating physician, PRE-authorization is not possible, but the patient must still be treated immediately since they have arrived emergently or urgently under such circumstances. Based on federal and state laws, payers are not allowed to deny this care for medical necessity. Yet, it happens all the time. 

Payers also make decisions based on level of care (IP vs. OBS) or length of stay, whether you’ve requested and received authorization upon the patient’s arrival or not. They conduct post-treatment medical record audits and make decisions based on hindsight by non-treating physician reviews, both of which are contrary to federal and state laws protecting emergency services, as well as most insurance policies’ own language regarding emergency care.

  • TGF works to assist providers in these processes to ensure independence of physicians’ medical judgment and appropriate reimbursement for medically necessary care
  • TGF firmly believes that providers—rather than payers—should determine what care is appropriate, and we fight passionately to achieve this result
  • TGF assists in enforcing providers’ and patients’ rights to reimbursement for prescribed medical care