![]() The CDC describes it as necessary to the patient and diagnosis and not just a convenient service or provision. The term medical necessity is gaining more spotlight. It is becoming more important to keep everything within the healthcare industry in check. In America, costs of healthcare services are rising along with chronic diseases. Now more than ever you have seen filled ICU beds and lengthy hospital stays. COVID-19 has played a large part in overly stretched hospital capacities. Additionally, if a patient is unconscious and unable to go through the pre-certification process, this review stage is critical. Retrospective review is also useful to determine if services that were performed emergently were necessary. Sometimes denials happen because a patient’s insurance plan does not cover it. However, denials don’t just happen when the review team determines that something was not medically necessary. If the service is denied, then the provider can issue an appeal. ICD and CPT codes are examined and are either accepted or denied. The retrospective review process looks at the entire hospital stay and pre-authorization to determine if the billing is accurate and the services were medically necessary. It even occurs after the bill is submitted. As you may realize from the prefix “retro”, this step happens after you have received health services. Under the umbrella term of utilization management falls retrospective review. Keep reading to understand the intricacies of healthcare so you can get a better understanding of how insurance works. A retrospective review validates claims, payment, and coverage from services already received. The insurance and healthcare industry is a tricky field to navigate. ![]() If you did not have any supplemental coverage during this time, you could have paid up to $7,400 out of pocket. In 2016, Medicare recipients spent over $5,000 in out-of-pocket expenses.
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