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There is a Cure to Medical Necessity Denials

Did you know that claims for services that do not meet the requirements of medical necessity are getting denied instantly? Payers are increasingly more focused on the issue of medical necessity.

Medical necessity is difficult to define, since there are so many interpretations and they vary from payer to payer. Most typically incorporate the idea that healthcare services must be “reasonable and necessary” or “appropriate” based on the patient’s condition and current standards of care.


Sadly, the decision as to whether services are medically necessary are made by someone who has never seen the patient. Most payers use automation to review and deny claims. These are called claim edits. The edits ensure that payment is made based on a specific diagnosis related to specific procedure codes. Diagnosis codes identify the medical necessity of services provided.

CMS has the power, under the Social Security Act, to determine whether each situation is reasonable and necessary. Even if it is that they later determine do not meet medical necessity the scope of the service can be limited.

To make matters worse, if a carrier pays for services that they later determine to no meet medical necessity, they will recoup those payments. They can demand a refund or just deduct the amount directly from a future reimbursement check. They also have the right to charge interest.

If they determine that the provider has a pattern of billing for medically unnecessary services, the provider may face monetary penalties, exclusion from the Medicare program, and criminal prosecution.


According to the American Academy of Professional Coders (AAPC), there are 8 key steps to follow:

  1. List the principal diagnosis, condition, problem, or other reason for the medical service or procedure.
  2. Assign the code to the highest level of specificity.
  3. For office and/or outpatient services, never use a “rule-out” statement (a suspected but not confirmed diagnosis); a clerical error could permanently tag a patient with a condition that does not exist. Code symptoms, if no definitive diagnosis is yet determined, instead of using rule-out statements.
  4. Be specific in describing the patient’s condition, illness, or disease.
  5. Distinguish between acute and chronic conditions, when appropriate.
  6. Identify the acute condition of an emergency situation; e.g., coma, loss of consciousness, or hemorrhage.
  7. Identify chronic complaints, or secondary diagnoses, only when treatment is provided or when they impact the overall management of the patient’s care.
  8. Identify how injuries occur.

If your claim is still denied your billing company should appeal the denial. This will require additional work on their part. It takes a lot of work and time to appeal a denied claim. It is tedious work and billers don’t like doing it. It is hard-earned money and one of the many ways a good billing service earns its money. It also requires that the medical note supports the coding. If the appeal is handled correctly there is a good chance the denial will be reversed, and the claim will be paid.

“Tiger” Focus by Scott Ballard

2020 is well underway. I don’t know about you, but I found myself juggling my ‘to-do’ list.  Every day, it seemed I was jumping from one thing to another and adding more things to my already robust list.  I had so many projects, micro-enhancements, things that would make the staff more efficient and be value added to our clients.

I make lists and I’m pretty organized but even with that I seemed to come up short.  I’m always looking for a better way for something that will help me focus on what is important and pursue it with maniacal intensity.

And then I read an article called “Tiger” Focus by Confidence Coach Scott Ballard.  I shared it with a few colleagues, and they had the same reaction I did.  It leaves you with a sense of ‘wow’ so simple but often over-looked.  And now when I seem to stray, I think ‘Tiger Focus’.  It is a quick read but one that you can apply to your business and personal life.

Meet Dr. Ashley Keays

Sr. Ashley Keays
Sr. Ashley Keays

In 2015, after 11 years of family practice, Dr. Ashley Keays ventured into subspecialty care focusing on fibromyalgia management and the treatment of resistant depression. Dr. Keays made the shift because she was looking for a more rewarding and fulfilling career. She found it… and it absolutely changed her life.

Over the next four years, Dr. Keays and her team molded Keays Medical Group into a practice of multidisciplinary care, which uses different modalities of treatment to customize and individualize care plans for patients with a diagnosis of fibromyalgia and/or chronic resistant depression. When treating fibromyalgia patients, Dr. Keays and her team use a holistic approach, looking at their emotional health, sleep patterns, and their nutritional and dietary history. The Keays team utilizes physical rehabilitation, pain management with trigger point injections and osteopathic manipulations. In addition, they perform genetic testing to identify appropriate medications and supplements which assist in creating patient-driven goals, and the identification of triggers that create fibromyalgia flares. Keays Medical’s ultimate goal is the development of a functional flare plan that helps break the pain and associated symptoms when they present as well as to provide overall knowledge and awareness to our patients.

Chronic resistant depression is a diagnosis in patients that have failed one antidepressant medication. In 2017, Keays Medical Group adopted Transcranial Magnetic Stimulation (TMS) to treat resistant depression and has seen amazing results since its adoption. TMS was approved by the FDA in 2008 as a non-drug/non-invasive method of treating depression. Keays Medical has partnered with NeuroStar Advanced Therapy to bring care to this population. TMS uses a targeted pulsed magnetic field, which utilizes the same technology as an MRI (magnetic resonance imaging). While the patient is awake and alert, TMS Therapy stimulates areas of the brain that are underactive in depressed patients.

As a doctor, one of the most important aspects of delivering care is creating the right physician–patient relationship. It is vital to the success of an individual’s care plan. Dr. Keays has worked hard to develop an environment where patients feel that they are heard and involved in shared decisions that drive their own healing. After years of searching, it wasn’t until developing Keays Medical Group that Dr. Keays finally found a rewarding and fulfilling career.

Who is the MVP in your Office?

Every person, every task, every patient is important, but the front desk is the quarterback for the office. They set everything in motion. They get the nod as the MVP.

Scheduling the patient is the easy part but everything after that is tricky at best and of paramount importance. Before the patient comes in benefits need to be confirmed, referrals and pre-authorizations must be obtained and recorded.

Once the patient presents at the office there is a whole new set of responsibilities and must be done with laser accuracy. It doesn’t matter how good the nursing staff is or how good the doctor is because if the front desk didn’t do their job then that visit won’t get paid.

Maybe you think registering patients is easy, but it isn’t. This requires that all the patient’s information and the responsible party’s information be recorded accurately. It isn’t enough to just ask if anything has changed you must confirm all demographics and then make sure that the current insurance card is scanned into the record. People change jobs, move, and get married and companies change insurance plans and so it is important to check every time. Also, the patient’s name and the responsible party’s name, if any must be recorded in the chart exactly as it appears on the insurance card. If the front desk isn’t looking at that card and scanning it into the record, then that is a fumble and will cost you.

As the patient is checked in or as they schedule their follow-up visit take the time to collect copays and deductibles. This is critical during the first part of every year since patients haven’t met their deductibles yet. If your front desk staff is asking for payment at the time of service, then you have a very valuable team player. Lots of people are uncomfortable doing this so make sure your front desk staff has the skill set to ask for payment. Your patients won’t get as many billing statements and your practice will be rewarded with improved cash flow.

It’s true – it takes everyone on the team to make a practice successful and maybe you are lucky and have several MVPs but make sure one of the MVPs is at your front desk!

Account Resolution Specialist

The Account Resolution Specialist is responsible for researching, resolving and collecting on all assigned accounts and performs a variety of medical billing and collection duties under general supervision.


  1. Answer phones and resolve calls accordingly. This will include, but not necessarily be limited to, negotiating payment plans with patients, accepting payments over the phone, updating patient demographics, rebilling insurance and sending tasks to others for further review and follow-up.
  2. Works assigned collection lists.
  3. Researches and resolves claim denial and payment discrepancies by calling carriers, patient and clients, accordingly.
  4. Process all incoming facsimiles, emails, correspondence and voicemails timely.
  5. Complete all tasks received via the Onpoint dashboard, daily.
  6. Abide with HIPAA and PHI guidelines at all times.


  1. Excellent verbal, written and interpersonal communication skills.
  2. Proficient with Windows, MS Office, Google Drive, email and multiple web browsers.
  3. Excellent organization skills and attention to detail
  4. Demonstrates an independent work initiative, sound judgment and strong work ethic.
  5. Ability to handle multiple tasks simultaneously
  6. Experience with AMD practice management software a plus but not required.


  1. High school diploma or GED
  2. One year of experience in a health care setting, preferably with accounts receivables.

The above statements are intended to describe the general nature and level of work performed by people assigned to this job. They are not intended to be an exhaustive list of all responsibilities, duties and skills required of personnel so classified and employees may be required to perform other duties as assigned.

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