Medical Necessity

Health insurance is to pay for illness. Given the choice, some people would like it to pay for furniture, air conditioning, mini-vans, you name it. So some limits are needed to keep the price of insurance reasonable.

Health insurance contracts usually sum this up by saying they will cover only what is "medically necessary." The catch is, who gets to decide what is necessary? Pretty much, the insurer does it unilaterally and only changes if there is enough public outcry to potentially reduce the number of healthy people who enroll.

The definitions of what is medically necessary are becoming more and more limited. For instance, if you have pneumonia and your doctor puts you in the hospital to get IV antibiotics, the insurer will likely claim the hospital care was not medically necessary -- you can get IV antibiotics in certain "skilled care" nursing homes. Your doctor has to think of a reason why you were too sick to be in a nursing home.

The catch is, the rules are a secret. HMO's pay lots of money for lists of rules made up by companies who specialize in defining what is medically necessary, and they aren't going to share it with someone else for free. Besides, they know very well that if the doctors knew they could get the day covered by saying "XYZ" in the progress notes or ordering "PQR" procedure, they would be doing exactly that as much as possible. Doctors and hospitals end up learning the rules by trial and error -- which patient day was covered, and what did we have to tell them to accomplish it?



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©2000 Eileen K. Carpenter, MD