In our previous post, we outlined how optimizing the technologies and processes behind clinical care is critical to optimizing performance in a value-based environment. The next step on the journey “Beyond the Curve of Health Care” involves medical necessity.
Medical necessity can be burdensome, but its various rules must be followed to avoid significant penalties or revenue loss. Looking at it from a more positive viewpoint, medical necessity is also an important path to build medical and tax benefits to support the financial shift to fee-for-value reimbursement. The Centers for Medicare and Medicaid Services is increasing its medical necessity audits, which makes health care organization leadership a vital role in compliance.
Health care executives must understand a few elements to maximize medical necessity benefits:
- Stay familiar with compliance standards as they evolve along your value-based journey, and ensure protocols are in place so the organization operates correctly. In addition, nurses, specialists and other staff can be trained to help maintain medical necessity standards.
- Don’t violate standards by not knowing what’s coming. Using proper data tracking, making smart medical decisions and avoiding waste can mean the difference between financial benefits and huge compliance penalties.
- Never stop looking for overlooked or unused standards that may come into play as you optimize performance for a value-based future.
If health care leaders need further incentive to put medical necessity compliance near the top of the list, consider this: Since 2011, there have been $7.89 billion in overpayments to hospitals identified by Medicare recovery audit contractors.
Our next post will deal with how health care organizations track data through coding and documentation. For a more complete story of how providers should optimize performance under value-based care, download a copy of the Optum eBook, “Beyond the Curve of Health Care.”