Medical Necessity – What Does It Mean?

April 25, 2013

One of our first recommendations to patients that need surgery is to check their insurance policy. A phone call to their agent or review of their policy – to ensure that their procedure is covered – is a great start. The goal is to avoid any possibility of a denial of coverage or a financial responsibility surprise afterwards.

During this call or review, one of the terms that patients will likely encounter is that of ‘medical necessity.’ Medical necessity is a term used by the healthcare industry to delineate whether a patient truly needs a procedure. However, medical necessity is not as cut and dried as it may seem. Indeed, medical necessity can mean different things to different people and ultimately it can cause a great deal of confusion in patients who are just trying to understand their insurance options.

If they need help understanding this terminology, patients should speak to their primary care physician, specialist or surgeon. Their office will help determine whether or not the procedure is covered under the guidelines of the insurance plan. Remember, they will likely have dealt with similar situations in past. This verification of benefits is often performed when the patient first calls to schedule their consultation. Take, for example, an elective procedure that will quite obviously help the patient’s health. While the benefit is obvious, the condition may not pose an immediate threat to their health. Is the procedure therefore truly a medical necessity? Understanding how an insurance company deals with cases like these may help ensure that the surgery will be covered.

If for any reason, after the procedure is performed, your insurance company rejects the claim, make sure you assemble your physicians’ resources to evaluate the denial and see how it can be overturned through the available appeals process.

Patients should make a point of sitting down with their medical team to understand how their procedure will be treated by their insurance company. Doing so may offer some clarity before a major life event like surgery.

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Advanced Surgical Associates is one of the first exclusively surgical groups practicing in Union County New Jersey. And that is just the first of many firsts for ASA. For over 40 years, we have pioneered breakthrough surgical patient care in North Jersey in both general and weight loss surgery. ASA also offers gastric bypass, gastric sleeve and gastric banding to those suffering from obesity in New Jersey.
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