From the moment a patient enters a facility, insurance carriers can begin evaluating the care provided to confirm that it is reasonable and appropriate, denying payment of services if applicable standards of care are not attained. All services provided to a patient must be efficient and cost-effective, and with direct relation to the patient’s presenting conditions. Services may be denied, during concurrent review or after the patient has been discharged, for a variety of clinical rationales, including but not limited to:
- Lack of medical necessity
- Inappropriate level of care
- Experimental/investigational treatments
- Delay in service/discharge
- Re-admission for diagnosis
- Non-emergent diagnosis/treatment
Washington & West approaches every denied claim from the standpoint that the vast majority of admissions and services rendered are medically necessary, clinically justifiable and provided at the appropriate level of care.