PARSING “MEDICAL NECESSITY” IN HEALTH CARE

PARSING “MEDICAL NECESSITY” IN HEALTH CARE
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Terms and Definitions to Debate

DHIMC: https://lnkd.in/e9AmEhd
FOREWORD: https://lnkd.in/gywd_Ad

MEDICALLY NECESSARY CARE: The supplies and services used to diagnose and treat a medical condition within the standards of good medical care. The revenues from health insurance premiums spent to pay for the medical services covered by the plan. Usually referred as a ratio, such as 0.95, which means that 95% of premiums were spent on purchasing medical services. The goal is to keep this ratio below 1.00–preferably in the 0.75, range, since the insurance plan’s profit comes from premiums.

MEDICALLY NEEDY: Patients eligible for Medicaid whose medical bills and total income is below certain limits.

MEDICALLY UNNECESARY CARE: That part of a stay in a facility [case manager] determined as excessive to diagnose and treat a medical condition in accordance with the standards of good medical practice and the medical community. Excessive may be because stay was too long or available in a less costly or more efficient setting.

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