“Medically Necessary” or “Medical Necessity”

Report
Definition and Application of
FEDERAL MENTAL HEALTH AND
ADDICTION EQUITY ACT
Rhonda Robinson Beale,M.D.
Health Care Consultant
Legna Business Group
THE GOOD

Health Plans must disclose:
Benefit requirements
 Exclusions
 Management parameters

NATIONAL COVERAGE DETERMINATION

National Coverage Determination (NCD)states:
 whether
a particular item or service is covered or
excluded.
 the population for whom it may be covered.
 under what specified situations for payment.
THE GOOD

Under the MHPAEA, the expanded coverage
of MH/SUD treatments gives the opportunity
for consumers with chronic condition from
being pushed into the public sector “safety
net” for continuous care and/or paying out-of
-pocket for all the care due to maxing out
their day and/or visit limits for that coverage
year.
WITH THE GOOD COMES THE COMPLICATION
The Federal Mental Health Parity and Addiction Equity
Act, (MHPAEA).
The “Good”
• creates parity of benefits with medical/surgical coverage,
•eliminates previous imposed visit and day limits
•The “Complication
•must relay more heavily on three processes and sources of
evidence:
•health technology assessments,
•credible practice guidelines and
•medical necessity definition.
HEALTH TECHNOLOGY ASSESSMENT
Health Technology Assessment focuses on
answering these questions to determine
coverage:
 What
is it?
 Is it effective? ( how, when, for who?)
 Is special training needed?
 Is it comparatively effective and efficient?
 Is it safe?
PRACTICE GUIDELINES



Practice guidelines are a set of recommendations on
diagnosis, assessment and treatment approaches that have
been proven to be effective and/or generally accepted
standard of practice as defined by a credible subspecialty
organization.
Example: provider recommends swimming with Dolphins as
a treatment for depression.
Evidence to support treatment alignment


Use of the scope of acceptable treatment(s) or treatment
approaches as outlined in the practice guideline.
Use of the appropriate trained/experienced clinician(s) or milieu to
deliver treatments
THE FOUNDATIONAL COMPONENTS NEEDED TO
EXECUTE MEDICAL NECESSITY
How does the Autism field compare to more well established fields?
Key Components
Depression
Autism - ABA
Diagnostic Parameters
X
X
Scope of Treatments
X
Limited
Defined
Medical Necessity
X
Limited
Treatment/Response
Benchmarks
X
Limited
Level of Care
Guidelines (LOCG)
X
Limited
Establishment of
Provider Competencies
X
For BCBAs only
8
MEDICAL NECESSITY TRANSITION
TIMEFRAME

Due to the Kaiser settlement, MCO’s and
MBHO’s changed to a standard medical
necessity definition as of July 1st 2004.
“MEDICAL NECESSITY “ REDEFINED

Except where state law or regulation requires a different definition, shall apply the
following definition of “Medically Necessary” or comparable term in each
agreement with Physicians, Physician Groups, and Physician Organizations:
“Medically Necessary” or “Medical Necessity” shall mean health care services
that a Physician, exercising prudent clinical judgment, would provide to a patient
for the purpose of evaluating, diagnosing or treating an illness, injury, disease or
its symptoms, and that are (a) in accordance with generally accepted standards
of medical practice; (b) clinically appropriate, in terms of type, frequency, extent,
site and duration, and considered effective for the patient’s illness, injury or
disease; and (c) not primarily for the convenience of the patient or Physician, or
other Physician, and 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 peerreviewed medical literature generally recognized by the relevant medical
community, Physician Specialty Society recommendations, the views of
Physicians practicing in relevant clinical areas and any other relevant factors.
“MEDICAL NECESSITY "DEFINITIONSOPERATIONALLY DEFINING KEY TERMS

“Medically Necessary” or “Medical Necessity”
shall mean health care services that a
physician/clinician, exercising prudent clinical
judgment, would provide to a patient for the
purpose of evaluating, diagnosing or treating an
illness, injury, disease or its symptoms, and that
are:
(a)In accordance with generally accepted standards
of medical practice(GASMP) and
(b)delivered by a clinician who is actively licensed to
practice



board eligible or in the case of physician extenders certified
deliver services within the scope of DSM IV and CPT codes
covered by insurance
meets the qualifications for credentialing by insurance
“MEDICAL NECESSITY "DEFINITIONSOPERATIONALLY DEFINING KEY TERMS

Prudent clinical judgment- is interpreted as
the clinical diagnosis and case formulation
based on:
the appropriate use of the current DSM or its
equivalent in ICD as the classification system
for identifying critical clinical factors relevant to
the diagnosis and
 design treatment interventions that are relevant
to the diagnosis,
 case formulation and are based on evidenced
based practices guidelines or where absent
uses “generally accepted standards of medical
practice”.

KEY OPERATIONAL TERMS

Clinically appropriate, defined in terms of type, frequency, extent,
site, duration and effectiveness,
 • Type –practice guidelines, research models and sources for
GASMP, ( expert consensus panels)
 • Frequency – based on practice guidelines, successful
research models, MBHO and/or national benchmark data
 • Extent of treatment– based on generally accepted treatment
domains in alignment with LOCG and/or practice
guidelines/GASMP
 • Site – based on MBHO LOCGs, practice guidelines, specialty
society evidence-based recommendations
 • Duration – MBHO and/or National benchmarks by like
populations
 Effective – based on reported response as aligned with
expected response according to practice guidelines and/or
research modeling or practice based evidence using valid
quantitative outcomes tools
"MEDICAL NECESSITY” DEFINITIONS –
OPERATIONALLY DEFINING KEY TERMS

“Generally accepted standards of medical
practice” (GASMP)- means standards that are
based on credible scientific evidence from:


Published in peer-reviewed medical literature,
Evidenced based consensus panels,
 i.e.Texas
Algorithm Group)
Evidenced based specialty society
recommendations,
 New technological assessments
 Credible practice based evidence

and not from
Single case studies
 Personal opinion

MEDICAL NECESSITY DENIAL CATEGORIES
Medical necessity denials may fit into one of
these categories as the bases for the denial.
 Inappropriate intensity of services –
too high or too low,
 too frequent or not frequent enough
 the restrictiveness of the treatment setting is not
needed

Treatment not aligned with practice
guideline(s) and no justifiable clinical reason
for exception.
 Delay or inefficient treatment delivery

THE NEXT FRONTIER – APPLYING MEDICAL
NECESSITY TO CHRONIC ILLNESS




making medical necessity determinations in individual
cases do not always address the particular needs of
beneficiaries with chronic conditions.
Chronic care differs from acute care, where the treatment
goal is improvement and/or cure, and end of life care,
where the treatment goal may be palliation.
The goal for a patient with chronic conditions may be to
prevent deterioration and/or to maintain functioning.
A patient with one or more chronic conditions may have a
medical need for, and accepted medical and nursing
practice may require, observation and assessment,
therapeutic care, and care management on an on-going
basis.
THE COMPLICATION
Parity sets the expectation of comparable
services
 Are
medical emergency rooms comparable to
true psychiatric crisis centers/front room
services?
THANK YOU!
RHONDA ROBINSON BEALE MD
[email protected]

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