What Is a Medical Necessity Analysis and How Can It Help Your Company?

Committing to treatment is a major decision. Not only does a person have to accept that they need help and be willing to ask for it, but they also need to find a treatment provider that will be able to meet their needs while also aligning with their goals and values. This can be a challenging and lengthy process, especially with the current demand placed on mental health service providers. With all of these barriers out of the way, one of the last things that can stand between a person and the care they need is the cost. 

Fortunately, insurance can cover much of this cost, but there may still be out-of-pocket expenses. Being transparent with potential clients about the pricing of services and what their insurance will and will not cover can help them make strong decisions about their care while ensuring that your organization will be receiving the payment you are owed.

A Medical Necessity Analysis Can Help

One way to navigate this process and come out with the best outcome for both your patients and your organization is to conduct a medical necessity analysis. Insurance companies must ensure that the services they cover for their prescribers are medically necessary. This means that the proposed treatment must match the diagnosis and symptoms and that it is intended to reduce those symptoms. As part of the behavioral health community, you want nothing more than to provide your patients with the best evidence-based care. You would not spend time or resources providing subpar or unnecessary treatment because that benefits no one. 

In reality, it is a little more complicated than that. Insurance companies look at the type of treatment, frequency, and setting. Therapy sessions in an outpatient environment might be approved, whereas that same treatment taking place in an inpatient setting might be denied. In this case, there is no debate about whether the specific treatment modality you chose to employ was effective and deemed to be medically necessary for your patient’s condition; rather, the insurance company took issue with the setting it took place. 

Similarly, treatment sessions taking place two times a week could be approved, whereas bumping it up to three times a week could lead to issues. Again, in this case, the treatment itself was not the problem, but the frequency was. Insurance companies often have strict standards and fine lines that, if you cross them, could lead to denials of coverage.

When an insurance company denies coverage for a patient, it can be more than just inconvenient; it can be extremely detrimental to their health and progress in treatment, thus delaying their recovery. In behavioral healthcare, treatment builds on itself. When a person first starts, they may be very apprehensive about the nature of the treatment, especially if this is their first time addressing a mental health issue. In this vulnerable state, building rapport and trust with a mental health professional and even peers in group therapy or support groups is a crucial step. With this rapport in place, amazing, transformative work can be done. 

If insurance intervenes in the middle of this and deems some aspect of the care plan to be medically necessary, it can be like hitting the pause button on progress, which can lead to a patient losing confidence, needing to start over, and possibly even leaving altogether. If there were any issues with insurance at the beginning of treatment, that potential patient might never get the help they need. Lost time and unexpected expenses can spell disaster.

Of course, there are repercussions for the treatment center as well. If insurance decides not to pay for something, that means your organization is not being reimbursed for the resources it pours into patients. Between paying therapists, nurses, and personal care assistants, staffing admissions representatives, and consulting with physicians, there are a lot of expenses to cover, and hiccups with insurance can cause significant problems.

Insurance companies can even revoke coverage retroactively if they deem the services provided to not be medically necessary. In this circumstance, patients might need to pay that money back, and treatment providers can face repercussions as well.

How Lightning Step Technologies Can Help

A medical necessity analysis can help you weave around these roadblocks. Careful documentation enables you to secure approvals and effectively appeal denials. This is where Lightning Step Technologies comes in. 

Our All-In-One system combines a CRM (Customer Relation Management), EMR (Electronic Medical Record), and RCM (Revenue Cycle Management) in one place. When you enter data at one point in the system, it automatically populates throughout the rest of the system so that you have all the information you need when you need it. Keeping detailed patient records with all their treatment plan details is as easy as typing them in once. A clinical staff member can edit the EMR, and a staff member working on medical necessity analysis can easily access it to move the insurance approval process forward without requiring numerous phone calls and emails to get the right information.

In addition to our comprehensive system, our Lightning Billing specialists know the ins and outs of insurance, and we can use our decades of experience to make sure your patients get the services they need while you get the payment they deserve. Not only can we assist in verifying benefits, but we can also perform medical necessity analyses to give your patients an idea of out-of-pocket costs ahead of time. 

Working with insurance companies is a necessary part of providing behavioral health services. With changing standards and confusing rules, it takes too much time out of your day to understand why your claims are being denied. At Lightning Step Technologies, we know that time would be better spent caring for your patients. Our Lightning Billing specialists are well-equipped to navigate the insurance process and assist you with verification of benefits, medical necessity analysis, and utilization review. We understand how to obtain approvals and make effective appeals in the event of a denial. Our billing services augment our All-In-One system to provide you with industry-leading technology made by experts. By using our system, you no longer have to worry about a separate EMR, CRM, and RCM; Lightning Step keeps it all in one place without sacrificing quality or flexibility. To learn more about our All-In-One system, schedule a demo today.

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