The Client Challenge
While undergoing growth and expansion in its pain division, an ambulatory surgical center (ASC)’s leadership sought to ensure its new practitioners were adhering to the organization’s quality standards. They proactively identified pain stimulator implant procedures as a focus area.
Since treatment often involves pursuing alternative therapies first, followed by a trial of the implant when other options proved ineffective for pain management, an external evaluation of procedural medical necessity was a proactive effort to identify potentially unnecessary procedures that may also have resulted in inappropriate billing.
MEDICAL NECESSITY REVIEW IMPROVEMENT OPPORTUNITIES
- New medical service/procedure due diligence to ensure treatment appropriateness
- Improve quality and effectiveness of patient care by eliminating unnecessary treatment
- Reduce costs for patients, physician investors, and the facility
- Lower potential legal risk
The Solution
The ASC worked closely with Greeley undertake a comprehensive medical necessity review covering several interventional pain medicine practitioners and nearly 100 outpatient procedures. Using a tiered approach, two board-certified, actively practicing, external physician reviewers first evaluated medical necessity for the trials followed by the permanent implant procedure. They reviewed all medical records and patient histories to determine whether symptoms were intractable and pain not relieved.
The reviewers used a standardized scoring methodology that assessed care as either appropriate, questionable, or not appropriate. For each procedure, reviewers identified opportunities for improvement in care, including diagnosis accuracy, clinical judgment/decision-making, technique, delay in diagnosis or treatment, and documentation. The ASC received a concise report that would enhance the organization’s continuous improvement efforts as well as supply data for ongoing tracking and trend analysis.
