The Paramount Health Solutions team of industry expert physicians, coding auditors and UR/Case Management professionals look at all types of denials.
Expert coding ensures compliance with both the Centers for Medicare and Medicaid Services (CMS) regulations and commercial insurance regulations regarding quality and reimbursement. PHS’s coding team takes a unique perspective to coding denials. With the belief that each record stands alone, only a thorough review of the medical record will determine the correct coding for each claim. Rather than simply rebilling the claim, our team conducts a thorough analysis of the medical record and writes a detailed appeal to defend the codes and support the DRG billed.
There is not an all-encompassing list of medical necessity criteria, nor one agency or governing body overseeing medical necessity denials. Often medical necessity is defined as “Specifically referring to services, treatments, items, or related activities which are necessary and appropriate based on medical evidence and standards of medical care to diagnose and/or treat an illness or injury or; treatments, services, or activities that will enhance a patient’s health or that the absence of same will harm the patient.”
Different insurance providers and payors have differing medical necessity criteria, which can be confusing and can lead to claim denial. However, medical necessity denials can be appealed and often have a good chance of being overturned. The Paramount Health Solutions team of expert clinicians will review the denial letter and medical record to gather critical information in authoring an appeal using industry-standard criteria, such as InterQual Criteria as a reference.