Two Important Words

Before I go too deep into the world of rehabilitation utilization and clinical review I think it important to establish an understanding of one very key phrase: Medical Necessity.  Just about all decisions involving the health care of an individual revolve around those two words.

You would think, that with basically two words ruling healthcare, how complicated could it get right?  If that is what you may be thinking then it is your homework to watch any politically driven TV channel for a few hours a day for the next week.  I will even let you choose the channel; C-Span, CNN, FoxNews, etc. For extra credit, go to an open congressional session at your local state capital (be sure to bring a cushion and eye drops).  You will see what goes into definitions when policies makers are involved.

Where the trouble comes is in defining of the two words together as a phrase.  Then each part of the phrase’s definition need to be further defined. The next logical step in a money hungry world is to then apply these definitions in how money is used.  Funny thing about money, everyone wants it, but few want to give it away. So some people feel like one definition of medical need affects their money too negatively, so they come up with their own definition.  Then the next company does the same thing. Then the next. At some point the government gets wind of all this and starts to question the legality and fairness of it all. They start to add their definitions, rule and laws.  Anyway, it gets messy!

Not Just One Definition

If you have come to this blog looking for one catch-all definition of medical necessity of rehabilitation services (physical therapy, occupational therapy, chiropractic, speech therapy, etc) I have some bad news.  That does not exist. Sorry. My goal of this post is to help you think a little differently about medical need and then use those thoughts in how you go about trying to establish it in your clinical practice (more posts to come on that).  Thanks to the huge monetization (is that even a word?) of medical services over the last few decades medical necessity is ultimately defined by who pays for the service. Yes, providers have a say, patients have choices; but if the service is not paid for then it likely is not going to be given. Even pro-bono services are paid for by someone (grants, etc) that sets up rules as to who most deserves that free service.  If the patient still really wants the service, then they either need to pay or find a different payer.

Healthcare payers only want to pay for services that are really needed, but some see various services more or less necessary than others.  My kids really think Fortnight is necessary, I am the payer, I don’t see it as necessary; we don’t own Fortnight! Simple enough example? Again, it is how “needed” is defined that creates all the problems.  Like I said above, this definition is likely going to be largely influenced by health insurance and then regulated to some degree by local or national governments. It most definitely is not “what the doctor says goes” if the patient wants their service paid for by their health plan. That may be considered, but is not the final word.  Furthermore, be aware that some health plans may define medical need differently when talking about different provider types (i.e. physician vs therapist).

Definitions (Not Definition)

In an article at FindLaw.com it states: The “medically necessary” definitions for private health insurance are found within the contracts between the patients and the insurance companies.  Did you notice the word “definitions” was used and not “definition”? They also go on to explain that these definitions can then further be complicated by state regulation.  So what about the Affordable Care Act? No, I have not read the whole thing, but based on my research and what is said at FindLaw is that the ACA only defines what should be included in an essential healthcare package. It does not go so far as to define under what circumstances those services should be used.

The American Medical Association has come out with some statements for consideration of medical need.  However, there is no law that a healthcare payer has to adopt any or all of them.  They have recommended medical necessity as:

Healthcare services of products that a prudent physician would provide to a patient for preventing, diagnosing or treating an illness, injury, disease or its symptoms:

  1. In accordance with generally accepted standards of medical practice
  2. Clinically appropriate in terms of type, frequency, extent, site and duration
  3. Not primarily for the economic benefit of the health plans or for the convenience of the patient, provider, etc.

I will share some other examples, but as you do your own searching on this topic you will see that many private definitions actually come very close to this definition.  The hard part is that each statement within the definition are a bit vague and where most of the debate is centered.

Since we as a whole cannot always ethically regulate our selves, those that pay for the services we provide have decided to do so.  Time for another cliche? One bad apple spoils the bunch. I think that fits nicely. In upcoming posts I will share real life examples of the bad apples in our bunch.

Here are a few other Medical Necessity definitions I found:

Medicare: Services or supplies that are needed for the diagnosis or treatment of your medical condition and meets accepted standards of medical practice.

  • Federal Criteria: Established through National Coverage Determinations (NCDs)
  • Private Plans Criteria: Established through Local Coverage Determinations (LCDs) that may be not be similar to national criteria but must abide by state and federal mandates.

CignaExcept where state law or regulation requires a different definition, “Medically Necessary” or “Medical Necessity” refers to health care services that a health care provider, exercising prudent clinical judgment, would provide to a patient. The service must be:

  1. For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms
  2. In accordance with the generally accepted standards of medical practice.
  3. Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient’s illness, injury, or disease.
  4. Not primarily for the convenience of the patient, health care provider, or other physicians or health care providers
  5. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury, or disease

For these purposes, “generally accepted standards of medical practice” means: Standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, Physician and Health Care Provider Specialty Society recommendations,The views of physicians and health care providers practicing in relevant clinical areas.
Preventive care may be Medically Necessary, but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents.

APTA: For some reason I could not find a well worded definition on the website of the American Physical Therapy Association website. I know there was some work with Center for Health Policy at Stanford University and APTA to establish model language back around 2011. If any readers have a link, please post in the comments! However I did find some statements from them that you may find helpful

  • As the US health care system moves toward value-based payment, quality reporting is becoming very more prominent
  • Make sure there are actual grounds for appeal, make sure your documentation really supports your case
  • It is important to understand and remain current on the coverage and payment policies of Medicare, Medicaid, Workers Comp, automobile liability, private insurers.  

Take With a Grain of Salt

At this point, physical rehabilitation professions as a whole need to really take this with a grain of salt.  A big grain, lets just go with a horse’s salt lick block. Much of what we do is not yet very well backed by research.  Sure there are studies to say it helps, or does something positive. That is not enough. Unfortunately there is almost nothing to define actual dosage, frequency, intensity, style, modality and timing for most conditions we see.  What defines our “generally accepted standards of [physical therapy] practice”? The APTA? Multi-clinic conglomerate number mills? Physician owned practices? Small clinics? Cash-based? And which of these groups do we use to establish clinically appropriate services?  Maybe the practices that continue to use ultrasound with every patient? The ones that write 3x a week for 8 weeks for every plan of care? The ones that only provide manual care? Of course none of this kind of stuff is for the economic benefit of the provider right? What about providers that get as good of results with 4 visits as those that use 12?  So where is the line drawn? Enter the health plan policy (read CONTRACT).

Since we as a whole cannot always ethically regulate our selves, those that pay for the services we provide have decided to do so.  Time for another cliche? One bad apple spoils the bunch. I think that fits nicely. In upcoming posts I will share real life examples of the bad apples in our bunch.

Take Action

So what is a provider to do about this?  Low road, middle road or high road…

Low Road – clinician version of three-year-old-in-the-candy-store-tantrum through continual complaints, arguing and whining to anyone and everyone that will listen.  Never look inward to see if you can improve your assessments, documentation or get more understanding of the health plans you contracted with. Remain bitter, hate your job, place blame, think you are the victim.

Middle Road – Continue to rely heavily on “the doctor prescribed it” ideal and stressed office workers to establish medical need for you.  Continually deal with appeals for more visits and when needed extend yourself to get a bit more information to those paying for your services.  Remain confused, be frustrated with your job, potentially burn out.

High RoadEducate yourself whenever possible about the health plans you contract with.  Read contracts and don’t sign until you completely understand the plan and its limitations.  Work closely with office staff and get them to research for you on who defines what and how. Find and study the clinical practice guidelines established by your peers.  Understand the recommendations given and how strong or weak their recommendation. Do the same with those created by the payers (Did you even know health plans should have their own guidelines?  Yep, I have even helped establish the PT ones where I work; they are over 900 pages long!). Compare them and check references. Check for resources from your state health commission and what regulations they have.  Be aware that most payers are NOT contracted with you to get patients to 100%. There will be exclusions, know those. If you believe the doctors recommendation of PT 3x a week for 8 weeks is really needed then prove it with proper tests, measures and functional reports.  Remain a professional, be empowered in your career, avoid frustration through understanding.

“Ya, Ya Witty PT, sounds great, just have to find that golden unicorn that takes you on the high road and does your daily documentation for you while on the journey,”  you say. Yes, that is a somewhat perfect goal, but it is obtainable. If even in parts. I have seen the notes of these providers. I have talked with them on the phone.  They are a joy to talk with because they get it, and can always demonstrate true need and understand the limitations of the payer.

So maybe the whole bunch is not rotten.  I would actually say the majority is not. Those rotten apples just stink really bad.  If affects us all.

One last recommendation.  Stop allowing your patients stay in the dark about their health plan.  They also signed a contract with the health plan right? Ask them to learn about their health plan.  Of course, you still have to go through the processes of authorization as per contract, etc; but encourage your patients to find out what their health plan pays for before they start PT or by the next visit.  Ask them if they know how their plan defines medically needed services and if not to find out. That they need this information so you can establish treatment goals with them. Other providers do this all the time.  Personally, I have had my dentist, a local hospital system, my boys’ ENT, my boys’ audiologist and more ask me to do this same thing. In the end I am glad they did. It forced me to better understand our plan and when the provider comes back to say a certain recommended service is not covered then I totally understand and don’t get mad at them.  You can also educate them that what you or another provider defines as medically necessary may not be consistent with their health plans coverage rules. However, all health plans have appeals processes. Which may include the right to an external review if first appeals are not successful ( US dept of health and human services ).  

As a very personal example, my wife and I have two boys that have idiopathic hearing loss.  It was discovered at a very young age for them both. At the time, the older one was about to start school.  After all the doctors visits and testing it was determined that the best course to get them started with hearing aids.  There were no indications that the hearing would ever come back and that it would likely progress. The doctor was almost certain that hearing aids would be covered at least in part.  He did not give a full guarantee but said they would get things started. Well, we came to find out that our health plan at the time did not cover a dime for the hearing aids. Even after going through the appeals process it was determined that even though the kids required the hearing aids to be able to hear and participate at school it just was not a covered benefit.  It was hard, but we did what we had to do. We shopped smart and found a great audiologist that was willing to work with us and got us a great deal on two pairs of hearing aids. We were bitter for a time, and it is still hard to believe. Ultimately, when we looked into it, they were right, it was just an exclusion of the plan. They had defined that hearing aids were not medically needed in our childrens’ situation.

I hope that this post has given you some things to think about.  That it has in some way changed the way you look at medical need of the services you provide.  That maybe it will make you want to work a bit more closely with your patients in decided just what care they get and how much.  Educating them on how far their plan will take them, and if they want to go further then they will need to think about other payment options.  Maybe you felt a need to look up a few clinical practice guidelines (check out https://www.PEDro.org.au) and see what they “experts” recommend. You might be surprised what you see.  I don’t claim to be the foremost expert on medical need. It is such a complex topic and is different for each situation. What I do know is that there are many clinicians that could use a bit more understanding when it comes to this topic.  An understanding that medical necessity is not a one-size-fits-all. It is more like a wardrobe – a closet full of some things that look great and work well together and others that are plain or even a bit ugly; but if you are going to use the clothes, then you have deal with how to make it fit and look presentable.

As always, I welcome your comments and thoughts.  


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