Keys to Understanding Possible Exceptions to MNC

In yesterday’s blog we discussed medical necessity Criteria ( MNC) and stated that we would review MNC exceptions today. 

Learn the keys to understanding exceptions related to Medical Necessity Criteria.  Exceptions covered will include clinical judgment, geographic variance, accessibility of care and determination of what is “essential.” Exceptins to MNC are important to good quality care and quality health care management. Accrediting bodies such as NCQA and URAC address the need to make exceptions when clinically indicated. MNC are subject to different, yet equally defensible interpretations by different clinicians.

 

• Exceptions to standard MNC should be reviewed by a physician or peer reviewer based on accepted standards of good medical practice, and all details of the case should be provided to assist in the decision making. 
• Exceptions may also be based on geographical variances in availability of treatment services.  Cases for this can particularly be found in rural or medically underserved areas. 
• When a medically necessary service is not available the patient will be able to either obtain outside services, or treatment at a higher level of care based on determination of what is “essential” for the optimal care of the patient.

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Key Areas of Accreditation Due Diligence

Yesterday I had two interesting calls yesterday with potential clients. Both were required to be accredited but had some latitude about the specific accreditation body.   They had a number of questions about which accreditation body that should chose. Below I have outlined a number of questions that an organization should think about when picking an accreditation agency.

The following areas are important to consider during an organization’s due diligence:

• Has the accreditation organization established an excellent reputation in the industry?
• Is the accreditation organization recommended by several respected professionals?
• Has the accreditation entity established a reasonable and competitive cost structure?
• Does the accreditation entity’s staff exude professionalism in every possible venue?
• Is the accreditation organization known for treating potentially accredited healthcare organization’s staff with respect
• Does the staff at the accreditation entity go the extra mile in collaborating with healthcare staff to interpret standards?
• Is there a formal, user friendly process for obtaining information related to interpretation of standards?
• Remember to review the standards to see if they are relevant to your organization, to ensure that no other accreditation entity provides a better match, and that the applicable standards are not prohibitive for your organization 

Evaluating Healthcare Accreditation Entities

I am often asked what is the best  accreditation organization.  Typically I am asked this question by a client that has just engaged our services and after they have chosen an accreditation entity.  I asked our expert accreditation consultant, Rachel Walker, SVP of BHM’s accreditation and QI Division to help out.  She wrote two articles in our February newsletter that I thing are helpful. Please see our newsletter for more details.

When it comes to spending your “accreditation dollars” it can be a jungle out there.  Not only are there a variety of accreditations, but also a vast choice in entities which provide them.   Find out what to consider before spending your money on accreditation according to BHM’s accreditation expert Rachel Walker.  Learn important keys to identifying the accreditation entity which will not only support your organization in reaching goals and objectives, but also be more beneficial to your organization when taking into consideration the “big picture”. 

Learn the essential keys to accreditation due diligence.  This article will feature concrete questions which should be part of any organizations due diligence process, along with expert advice from BHM’s accreditation expert Rachel S. Walker, RN, B-C, CHCQM.