So, who defines "medical necessity"?

[BabyPsychDoc]

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This week of NEJM has a perspective article on parity:


http://content.nejm.org/cgi/content/full/359/2/113?query=TOC

Now, this may seem a dumb question, but who actually decides whether the treatment is "medically necessary"? Insurer? Physician? Ombudsman?

 

[Anasazi23]

I imagine it would be most likely how it is now. The physician's decision with the ability of the ins. company to challenge this. It would probably how we commonly call in non-approved treatments to medicaid now. i.e. restoril and benadryl haven't worked for sleep. Therefore I'm overriding for Ambien.

 

[Faebinder]

This will never be fixed as long as we are held liable for people who want to kill themselves actually doing it after the Xth attempt. We will get malingering patients who dont want to kill themselves all the time. Some old stubborn alcoholic a$$ that refused to get an EGD for his own good after vomiting blood.... call psych. Further, our really ill people actually cost the in system way more than they bring in. They often are on multiple medications forever and are often unemployed. Insurance companies want quick fix diseases so they can make money... chronic diseases are a nightmare for them.. hence they ask about diabetes, smoking, etc (things that need a lot of medical followup).

At the same time think of it as good job security.... there will always be a psych consult so that if all attempts to get the person out of the risky behavior / suicidal ideations fail then the medical service cant be blamed... instead they can say "We called psychiatry and they said the patient was not a danger to themselves."