Medical Necessity

Benefits at a Glance

  • Reduce denied claims and increase revenue
  • Reduce the risk of fraud
  • Enable schedulers to focus more time on customers
  • Educate physicians on approved procedure diagnosis codes

Automate Screening to Assure Medical Compliance

Don’t get stuck with an unpaid bill.  Reduce claim denials, speed up reimbursement, and improve patient satisfaction with Medical Necessity, a denial prevention solution.

Available as an add-on to QES, Medical Necessity verifies in real-time that a patient’s requested procedure or test CPT® code(s) matches the appropriate ICD diagnosis code(s) provided by the physician to qualify for payments and reimbursement. By verifying compliance for Medicare or other insurance carriers, both you and the patient will know immediately who’s responsible for payment. This leads to improved patient satisfaction and fewer A/R days for your organization.

By improving overall compliance efficiency, Medical Necessity also helps your organization eliminate costs associated with submitting non-covered claims and resubmitting returned claims. This important add-on module for QuadraMed Enterprise Scheduling offers a number of features to drive this efficiency—starting at the point of scheduling.

Features & Benefits

Reduce Denied Claims and Increase Revenue

Medical Necessity streamlines the process of ensuring that medical guidelines are met by matching ICD diagnosis codes to appropriate CPT procedural codes. It identifies which procedures need to be checked for medical necessity and immediately prompts the scheduler if requested procedures and diagnoses fail to meet medical guidelines.

  • Can be used across several facilities
  • Automatically prints or e-mails waiver forms
  • Allows unlimited insurance carriers
  • Establishes customizable, payer-specific procedural codes based on updated CPT and ICD codes
  • Sub-second online pass/fail response
  • Forces highest levels of specificity for full Medicare compliance
  • Offers a variety of report creation options
  • Policies are updated monthly instead of quarterly so users have more accurate and up to date information

Reduce the Risk of Fraud

By automatically verifying compliance for Medicare or other insurance carriers, financial responsibility is properly identified and the risk of potential fraud and abuse is reduced.

Enable Schedulers to Focus More Time on Customers

Schedulers can automatically fax or email advance beneficiary notices (ABNs) to the proper parties at the time of scheduling. Patients are informed prior to their appointments and benefit from a more efficient, customer-focused process. In addition to numerous reports, all compliance data is made available and can be shared with your other information systems.

Educate Physicians on Approved Procedure Diagnosis Codes

The system encourages physicians to provide accurate diagnosis codes when ordering an appointment. This helps ensure fewer mistakes and promotes efficiency across the board.