Instant Medical Necessity Checking

Medical necessity is one of the leading reasons for claim denials, which reduce cash flow and revenue, leading to additional costs in claim rework and resubmission. “According to Beckers CFO, Transunion stated that a hospital stands to lose on average $960,000 per year without an effective medical necessity program.” InSight Medical Necessity helps you simply and efficiently avoid the expense and revenue loss hospitals and health systems 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.

Rely on InSight Medical Necessity to provide:

  • 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 to 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
  • Electronic signature

“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

Automatically Generates Medicare ABNs and Commercial Notices of Non-Coverage

For patients whose services are not covered, InSight Medical Necessity automatically generates the required Advanced Beneficiary Notice (ABN) or patient waiver form, using up-to-date CPT, HCPCS, and ICD-10 codes in a date-sensitive format. The software connects directly to your chargemaster file to reflect actual pricing in the ABN.

Access to Local Coverage Determination Policies

InSight Medical Necessity gives your staff instant access to up-to-date LCDs. Medical records departments especially benefit from faster access to the latest LCD policies instead of having to go through fiscal intermediaries.

Customizable Keyword Picklists

InSight Medical Necessity’s customizable picklists accommodate users who have limited coding knowledge so they can more easily choose appropriate procedures when performing medical necessity verifications.