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Health Tracking

FROM THE FIELD

Prospects For Improved Decision Making About Medical Necessity

With The Backlash against managed care, medical necessity has become the focus of increasing controversy.¹ California’s health care marketplace has provided some unique opportunities to understand the role of medical necessity in managed care decision making, as the legislature and stakeholders have discovered how little consensus there is on its meaning, ownership, and application.²

Nevertheless, many decision makers agree that medical necessity decisions generally involve authorizing treatment for an individual patient. These differ from coverage decisions, which set organizational policies regarding the coverage of treatments for populations of patients with similar conditions. Both types of decisions require medical judgment, and . . . [Full Text of this Article]

Study Methods

 

Research Results

 
Medical necessity decisionmakers.Variations in process and contractual definitions.Best practices in decision making.Better communication.Role of legislation and regulation.LegislationRegulationJudicial actionAccreditationMarket and performance incentives

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