InSight Medical Necessity®
More than 40 percent of healthcare organizations estimate that 10-15 percent of their claim denials are related to medical necessity errors
— Craneware industry research
Medical necessity is one of the leading reasons for claim denials, which reduce cash flow and revenue and lead to additional costs in claim rework and resubmission. Industry statistics reveal that hospitals without a medical necessity program face an average of $960,000 annually in denials. InSight Medical Necessity helps you simply and efficiently avoid the expense and revenue loss those hospitals face.
InSight Medical Necessity serves all parts of your organization that need instant access to medical necessity requirements, from admissions and order-entry to medical records and external practices. Medical necessity and prior authorization policies are continuously updated for major U.S. payors, including state, federal, commercial, and non-profit payor organizations.
- timely access to medical necessity requirements for major U.S. payors, and prior authorization warnings for all payors
- immediate access to Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), and commercial payor policies, plus customized policies based on payor denials
- customizable picklists accommodate users who have limited coding knowledge
- advanced checking that includes prior authorization requirements, age and gender, frequency limitations, non-covered services, inpatient-only procedures, dual diagnosis requirements and more
- medical necessity failures reported by physician and CPT code
- Advanced Beneficiary Notice (ABN) or waiver forms automatically generated for potentially non-covered services, with links to the chargemaster file to reflect actual pricing in the ABN