“Convenient” Doesn’t Equal “Necessary”

Insurers will pay only for services deemed to be medically necessary, based on the patient’s chief complaint or additional conditions that require work-up or focused attention. Services provided out of “convenience” for the patient will not be considered medically necessary if the patient did not have any specific complaints relating to the service. This often happens in specialty practices with subspecialists within the same group practice.

For example, in an ophthalmology practice, the patient comes in to see the general ophthalmologist. Because he has traveled three hours to get to the clinic, he also will see the cataract specialist, the retinal specialist, and the glaucoma specialist. The patient did not have any complaints—rather, the patient had seen these providers in the past and it was felt that he should be “checked on” while he was in the office. In other words, the services were not medically necessary.

If you were to think about it from the payer’s perspective, you would wonder why the general ophthalmologist cannot “check on” all areas of the eye. If a problem is then identified, then medical necessity has been identified and a second visit may be supported. There is immense potential for excessive fraud and abuse in allowing these types of services to be reimbursed at an unlimited capacity.

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 406 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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