Prospects for improved decision making about medical necessity

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...

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Bibliographic Details
Published in:Health Affairs 2001-01, Vol.20 (1), p.200-206
Main Authors: Singer, S J, Bergthold, L A
Format: Article
Language:English
Subjects:
Accreditation
Audits
Benchmarking
California
Case studies
Certification
Collective action
Communication
Consumer protection
Consumers
Decision Making
Decision Making, Organizational
Directors
Documentation
Group Processes
Health care
Health care industry
Health care policy
Health insurance
Health maintenance organizations
HMOs
Humans
Independent practice associations
Insurance Coverage
Interest groups
Interviews
Interviews as Topic
Law
Managed Care Programs - legislation & jurisprudence
Managed Care Programs - organization & administration
Medical technology
Medical treatment
Medicine
Needs Assessment
Physicians
Public health
Quality control
Refusal to Treat
Standardization
Studies
Telephone hotlines
Transplants & implants
United States
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Summary: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 thus both mix considerations of payment and clinical factors. Differences in coverage policies and in the application of those policies to individual decisions contribute to variation in managed care decision making. Previous research has found considerable variation in the process and criteria used for decision making in both public and private plans. Presented is research which was aimed to understand more precisely what type of variation exists and whether more clarity and consistency in medical necessity decision making could make a difference to consumers and providers.
ISSN:0278-2715
1544-5208
DOI:10.1377/hlthaff.20.1.200