Improving "medical necessity" acceptance by health care providers and consumers.
A major problem for patients and providers has existed since establishment of peer review and authorization agency medical necessity guide lines, because physicians and patients who receive denial of proposed procedures and tests on the basis of so called "medical necessity" presume that the authorization agency considers the proposed procedure or test to be medically unnecessary, meaning of no health value to the patient. This may well not be the case. Both providers and consumers can be expected to be more accepting of negative authorization decisions if the principles of continuous quality improvement are brought to bear on the authorization process.
Integrated Healthcare Strategies, Inc., Newport Beach, CA.
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Hepps
D003659:Decision Making, Organizational; D017408:Guidelines as Topic; D006300:Health Services Misuse; D007345:Insurance Claim Review / Q000592:standards*; D007400:Interprofessional Relations; D018024:Peer Review, Health Care / Q000592:standards; D011366:Professional Review Organizations / Q000592:standards; D017749:Total Quality Management / Q000458:organization & administration*; D014481:United States