Why Is Medical Necessity Review Needed For Behavioral Health Services?

Medical necessity review for behavioral health services is necessary to make sure that the services provided are medically necessary for the patient. The term medical necessity indicates the coverage that is offered under a benefit plan. A detailed medical chart review can identify whether the documentation supports the medical services or the level of care provided to the patient. To avoid delays and denials in reimbursement, it is important to ensure that the adequate level of care is reported.

What Is Medical Necessity?

Health plans have their individual definitions for medical necessity and this has an impact on how they determine which medical services they will cover. This definition will be usually provided in the policy. Typically, medically necessary services are those,

• Provided for the diagnosis, treatment, cure, or relief of a health condition, injury, illness, or disease. Clinical trials for experimental, investigational, or cosmetic purposes may not be covered under the policy.
• That are necessary for and appropriate to the diagnosis, treatment, cure or relief of an illness, health condition, injury, disease or its symptoms.
• That are within the generally accepted standards of medical care in the community.
• Not solely for the convenience of the insured, his/her family, or the healthcare provider.

Health plans may also include provisions to consider how cost-effective the requested treatment is, whether alternative services/supplies are available for the covered services, and/or the setting where medically necessary services are eligible for coverage. For Medicare coverage, medically necessary services are healthcare services/supplies required to diagnose or treat an injury, illness, disease, condition, or symptoms of a disease and which meet the accepted standards of medicine. For Medicaid, each state may have its own definition of medically necessary services.

Chart Review to Determine Medical Necessity for Services Provided

When reviewing behavioral health medical records for medical necessity, a professional medical review company would be looking for information such as the following.

• A detailed medical history of the patient
• Diagnosis and treatments undergone
• Evaluation of violent tendencies/suicidal tendencies
• Medications prescribed, their dosages, and side effects if any
• Documentation regarding whether the behavioral health provider contacted the prescribing health provider
• Compliance or non-compliance with treatment
• Informed consent

In the case of a behavioral health patient, his/her need for different levels and settings of care is typically determined when they arrive at a treatment facility. The medical evaluation and medical records should show details such as the following.

• Biomedical complications/conditions
• Emotional/cognitive/behavioral complications or conditions
• Acute intoxication and/or withdrawal possibility
• Willingness to change
• Potential for continued use or continued problem
• Recovery/living environment

An important consideration is a doctor’s attestation that a service is medically necessary. The health plan may require the patient’s doctor or other provider to provide a letter of medical necessity. This enables the health plan and their assisting medical review services to evaluate the requested medical services and decide whether the requested service is covered by the plan. There are three types of evaluation as indicated below.

• Pre-certification review: This is conducted before the treatment is provided so that the insurer can review whether the requested service satisfies their medical necessity requirements. For this purpose, the letter of medical necessity, medical records, and the health plan’s coverage policies are reviewed.
• Retrospective review: It is conducted after the treatment is provided to determine if the services were indeed medically necessary. It helps identify whether the services were experimental or cosmetic in nature, and if there was indeed a need for emergency services.
• Concurrent review: This type of review occurs during the treatment to find out whether the ongoing treatment is medically necessary.

Medical necessity review for behavioral health services would also focus on the following details in the medical records:

• A correct diagnosis represented by an ICD-10 code and clinical grounds for the diagnosis
• Safety/risk factors
• How the patient functions
• Recommendations for treatment and level of care.
• Progress notes that clearly show the delivery of the requested services in keeping with the nature, frequency, and intensity prescribed in the treatment plan. A medical review team would be looking for evidence that the progress notes support specific claims and justify the payment. These give proof of the covered service delivered to the patient; date of service, start time and duration; treatment objectives; CPT medical codes for the particular services delivered; evaluation and clinical impression; the patient’s actual participation, his/her progress towards treatment goals, continuous evaluation of treatment strategy and whether any adjustment is needed, and whether there is continued need for services or medical necessity.

Documentation and medical chart review are very important aspects of behavioral healthcare and help in various ways such as – ensure continuity of care across the healthcare spectrum; coordinate healthcare services; provide a timeline of clinical services; help comply with Medicare, Medicaid and other health insurance requirements; support the claims billed; and help reduce improper insurance payments and insurance fraud.

Now, let us have a look at the use of NLP (Natural Language Processing) for medical necessity review for all medical specialties including behavioral health.

How NLP Can Help Streamline Medical Necessity Review

As healthcare data continues to grow exponentially, leveraging NLP technology becomes essential for efficient and accurate medical necessity and claims review. By automating the analysis of unstructured healthcare data, NLP streamlines processes, improves decision-making, and enhances fraud detection. Healthcare organizations that embrace NLP for medical necessity review and claims review can achieve significant cost savings, reduce administrative burdens, and ultimately improve patient care outcomes.

AI technologies including NLP (Natural Language Processing) NLP can significantly streamline and improve this review process by:

• Automated documentation analysis: NLP algorithms can analyze unstructured clinical documentation, such as physician notes and patient records, to identify key information relevant to medical necessity. It can extract and categorize data related to diagnoses, symptoms, treatments, and outcomes, providing a comprehensive view for review.
• Rule-based decision support: NLP can be combined with predefined medical necessity guidelines to create rule-based decision support systems. These systems can automatically flag cases that do not meet the specified criteria, assisting reviewers in identifying potential issues quickly.
• Anomaly detection: NLP algorithms can identify patterns and anomalies in medical claims by comparing them to historical data and established billing standards. This helps identify potentially fraudulent claims or billing errors that require further investigation.
• Language understanding and coding assistance: NLP can interpret complex medical terminology and automatically assign appropriate billing codes. It ensures consistency and accuracy in coding, reducing the risk of claims denials and delays.
• Fraud detection and prevention: By analyzing vast amounts of healthcare data, NLP can detect patterns indicative of fraudulent activities, such as upcoding, unbundling, or excessive billing. It enables proactive identification and prevention of fraudulent claims, protecting healthcare organizations and payers from financial losses.

The NLP tool’s functionality empowers the extraction, conversion, and mapping of free text into industry standards, enabling seamless interoperability and meaningful exchange of data assets. This capability unlocks the potential to derive deeper analytical insights from the data, facilitating valuable decision-making and analysis.