Q&A: Medical necessity documentation

Q: One of the biggest challenges for case management directors is gaining the physician’s cooperation with documentation as they continue to face high patient volumes. What approaches should be taken to get physicians on the same page as case management directors?

A: Case management directors have the opportunity to be proactive by seeking to prevent or minimize future denials, says June Stark, RN, BSN, MEd, adjunct instructor at HCPro and an adjunct professor at Regis College in Weston, Massachusetts. One of the best defenses is a strong offense. This can be achieved by including a physician's medical necessity documentation in all or most charts.

To best gain the cooperation of physicians, Stark recommends that case managers inform the physicians of the hospital’s denial situation, including the insurance company's response, the denial volume, and how his or her support can help prevent a denial from occurring. Physicians should also be in tune with the efforts of the Utilization Review (UR) nurse. The daily real-time chart assessments from the UR nurse an help prioritize vulnerable cases, alerting the physician to the charts that require additional documentation if he or she agrees with inpatient status.  

For more information on this topic, see April’s issue of Case Management Monthly.