Q&A: Medical necessity denials

Q. What are some common reasons for medical necessity denials and ways we can ensure medical necessity compliance?

A. Medical necessity or clinical denials are typically a top denial reasons for most providers and facilities. They are also known as hard denials, in that they require an appeal to request reconsideration. Denial reasons that fall under this category include:

• Inpatient criteria not being met
• Inappropriate use of the emergency room
• Length of stay
• Inappropriate level of care

The primary causes of medical necessity denials are the:

• Lack of documentation necessary to support the length of stay
• Service provided
• Level of care
• Reason for admission

Providers must ensure that their physician and nursing documentation clearly supports the services billed for and that the physician’s admission order clearly identifies the level of care. One of the most effective means of ensuring compliance is through the implementation of a clinical documentation improvement (CDI) program. This can either be an internal program or outsourced to a qualified vendor. A successful CDI program facilitates the accurate documentation of a patient’s clinical status and coded data.

For more information, see The Denials Management Training Handbook .

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