"Medical necessity" determinations--a continuing healthcare policy problem

Area of Science:

• Healthcare Law
• Health Policy
• Medical Administration

Background:

• Current structures and processes for medical necessity determinations have broad implications.
• Understanding these implications is crucial for all stakeholders in the healthcare system.

Purpose of the Study:

• To prepare for the American Health Lawyers Association's Public Interest Colloquium on medical necessity determinations.
• To summarize the history and current importance of medical necessity determinations.
• To identify stakeholders and their interests within the medical necessity determination system.

Main Methods:

• Historical review of medical necessity determinations.
• Stakeholder analysis identifying key parties and their interests.
• Issue identification for future colloquium discussion.

Main Results:

• The history and current importance of medical necessity determinations are outlined.
• Key stakeholders, including patients, providers, and payers, are identified.
• A preliminary list of issues for consideration is presented.

Conclusions:

• The colloquium will focus on potential elements of an ideal system for medical necessity determinations.
• Further discussion is needed to refine and improve current processes.
• Addressing stakeholder interests is key to developing an equitable system.