Is The Treatment Medically Necessary?
Case managers, utilization managers, and nurses for health insurers sometimes have the unenviable job of rejecting healthcare claims.
It’s their job to evaluate procedures, including chiropractic techniques, based upon medical necessity. However, it’s difficult for them, as medical generalists, to have a complete understanding of the chiropractic specialty.
This means that it’s up to chiropractors to understand what case reviewers are looking for — and to provide it or not be reimbursed. It’s also important to understand that questionable cases are often passed on to a third-party, or independent review organization (IRO) for a decision. The IRO sends the claim to be scrutinized by a chiropractic physician, who evaluates it strictly on medical necessity, established facts regarding medical necessity, and proven medical care guidelines.
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