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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Clarifying Medical Necessity Criteria

Our group is working with a number of clients currently and a key componenet wrking with both payers of healthcare as well as providers of healthcare is underrstanding and executing medical necesity criteria.  Care managers often struggle over how to intrepret the criteria fairly and povider struggle at how to express the criteria that an idividual patient is exhibiting. Medical Necessity Criteria (MNC), one of the most vital aspects of healthcare and treatment, is still very ambiguous.   Numerous definitions for MNC can be challenging for providers and practitioners to know just exactly how different interpretations can impact care.  Please see the article in its entirety by Robert Levine that  will outline what is essential to understand about Medical Necessity Criteria, and how personal interpretation maintains a role in treatment distinguishing between what is “beneficial” for consumer health and what is “essential.”  Please sign up for our newsletter.

In tomorrow blog I will review MNC exceptions.