Medical Necessity Solutions Designed for How Medicare Pays Today

Today‚Äôs outpatient Medicare payment system is complex and it is changing rapidly. Each year, an increasing number of services that were once paid individually are now packaged into one payment.This unpredictable payment logic leads to larger outpatient denials because packaging places a premium on key procedures.


Prospective Payment System Medical Necessity

Our solution prevents real denials because it is designed for how Medicare pays today. Our Medicare experts integrated the outpatient payment system into its design so that your staff:

greencheck Knows which key procedures are paid by Medicare
greencheck Doesn't over focus on unpaid packaged services
greencheck Correctly prices patient notices with packaged Medicare rates


Sample Information System Screen

*Per CMS: Notifiers may not issue ABNs to shift financial liability to a beneficiary when full payment is made through bundled payments.

Fee for Service Medical Necessity

The medical necessity process on most hospital information systems checks services individually, and without consideration of the packaging logic. This means your staff:

fail Doesn't know which key procedures are paid by Medicare
fail Focuses too much on unpaid packaged services
fail Incorrectly prices patient notices*