External Medical Necessity Review Case Study

This case study details the collaboration between Chartis and an ambulatory surgical center (ASC) to conduct a comprehensive medical necessity review. The objective was to ensure sound clinical judgment and the appropriateness of diagnoses and treatments. The ASC engaged two board-certified external physician reviewers to evaluate nearly 100 outpatient procedures using a tiered approach. The reviewers assessed the medical necessity of procedures, identifying opportunities for improvement in clinical judgment, documentation, and treatment appropriateness. The findings indicated that while no procedures were deemed inappropriate, a significant percentage received questionable scores, highlighting areas for documentation enhancement. The report generated from this review serves as a guide for continuous improvement efforts, aiming to enhance patient care quality and reduce unnecessary treatments. The review process is positioned as a proactive measure to ensure adherence to quality standards and improve billing accuracy, ultimately contributing to better healthcare outcomes.