PYA White Paper Provides Guidance on Medical Necessity

mednecessity-imagePYA has released a new white paper exploring best practices in medical necessity to help providers avoid denials and recoupments.  

A new white paper from PYA, “Medical Necessity—Current Status, Key Best Practices in Prevention of Medical Necessity Denials and Recoupments,” explores medical necessity across multiple service areas and offers guidance for healthcare providers to avert denials and recoupments.

Providers often find that some of their greatest challenges in providing and billing medical services lie in the copious and detailed documentation required for demonstrating medical necessity.  Failure to meet conditions of payment and coverage requirements may also result in denial of reimbursement.

PYA’s white paper addresses key areas of medical necessity, including directives, denials, excluded services, bundled services, investigational drugs, skilled nursing facilities and inpatient rehabilitation services, advanced beneficiary notification, and self-disclosure, among others.  It also offers guidance for staying compliant with medical necessity requirements.

According to the paper, “With the establishment of the Affordable Care Act, Recovery Audit Contractors (RACs), and increased surveillance by the Office of Inspector General (OIG), ‘medical necessity’ has become a key, and sometimes feared, buzzword for healthcare providers.  The term broadly governs numerous aspects of healthcare and can present challenges in billing, reimbursement, and compliance.”

PYA’s compliance team possesses a diverse range of expertise and experience that includes, but is not limited to, compliance program infrastructure and assessment, enterprise risk assessments, coding, internal audit, governmental investigation response, governance structures, patient safety organizations, patient safety evaluation systems, and Independent Review Organization services.  In addition, PYA has conducted more than 700 medical-necessity-related reviews on behalf of our clients, including expert testimony at the administrative law judge level.  PYA is committed to working alongside organizational leadership and front-line staff team members to mitigate risk and maximize overall compliance practices for organizations.

Martin Brown

Martin Brown


Denise Hall-Gaulin

Denise Hall-Gaulin


Joanna Malcolm

Joanna Malcolm


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