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Recently, many of our clients have found that more and more of their in-network, contracted claims which they have billed to the various payors are being denied, in whole or in part, for an alleged lack of medical necessity. This article provides some considerations to be made when dealing with payors who have denied claims based on medical necessity grounds.

Examine Your Contract

                Definition of Medical Necessity

Providers should examine their contracts with the payor at issue. First, determine how the terms “Medical Necessity” or “Medically Necessary Services” (or the equivalent) have been defined in your contract. Ensuring that the services in question comply with that definition will be critical to succeeding in any challenge to the payor’s denial of the claim. Should any challenge of the payor’s denial result in litigation or arbitration, your expert witness will also need to become very familiar with the definition included in your contract and be able to support that the services provided do meet the definition provided. Read More ›

On April 24, 2018, the Centers for Medicare & Medicaid Services (CMS) issued its Hospital Inpatient Prospective Payment Systems (IPPS) proposed rule for Fiscal Year 2019 (Proposed Rule).  Contained within the Proposed Rule was a notice from CMS of the closure of two teaching hospitals and the opportunity for hospitals to apply for the newly available graduate medical education resident slots under Section 5506 of the Affordable Care Act (ACA).  Read More ›

Massachusetts senators recently proposed a health care reform bill intended to reform the Commonwealth's health care system by controlling costs while improving outcomes. Read More ›

On March 2, 2017, the United States District Court for the District of New Hampshire issued an order (the Order) for a permanent injunction against CMS barring it from enforcing certain “policy clarifications” with respect to the calculation of the hospital-specific disproportionate share hospital (DSH) limit (42 U.S.C. § 1396r-4(g)).  As a result of this order, CMS is permanently enjoined from enforcing these “policy clarifications,” which States had used to reduce the DSH payments for many hospitals.  We anticipate the full scope of this injunction to play out in states around the country. Read More ›

The unexpected election of Donald J. Trump on November 8, 2016 has introduced a significant level of uncertainty in the health care industry.  Both President-Elect Trump and Republican congressional leaders have emphasized the repeal and replacement of the Affordable Care Act (ACA) or some of its key provisions.  As a result, providers, payers, and patients now face the prospect of a dramatically altered health care landscape three years after the ACA's key provisions took effect. Read More ›

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