Why You Can Never Document Well Enough

Changes to payer guidelines can indeed create challenges for doctors when it comes to documenting medical necessity. While it's not accurate to say that these changes make doctor's notes "never" correct, they can create difficulties and make it harder for healthcare providers to accurately document medical necessity. Here are some reasons why this might be the case:

Shifting criteria: Payer guidelines, including those from insurance companies or government programs, can change over time. What was considered medically necessary for reimbursement in the past may not meet the new criteria. Doctors may not always be aware of or immediately updated on these changes, leading to discrepancies between their documentation and the current guidelines.

Complex and evolving regulations: Healthcare regulations and guidelines can be complex, subject to interpretation, and constantly evolving. Doctors may not have the time or resources to stay updated on every change, which can result in discrepancies between their documentation and the latest requirements.

Administrative burden: Doctors are under significant administrative burden to document medical necessity correctly for billing and reimbursement purposes. Frequent changes in payer guidelines can increase this burden, making it challenging to keep up with all the updates while providing patient care.

Lack of standardization: Different payers may have different guidelines and requirements for documenting medical necessity, which can be confusing for healthcare providers. The lack of standardization in the industry can lead to discrepancies in doctor's notes.

Denials and appeals: When doctors' notes do not align with payer guidelines, there is an increased likelihood of claim denials. This can result in the need for time-consuming and resource-intensive appeals, further diverting healthcare providers' attention away from patient care.

"Medical Necessity exists and is required for EVERY lab ordered". ~Michael Sprintz, DO, DFASAM

To address these challenges, Cellarian has built a proprietary platform that is "patient specific, incident specific and payer specific". We partner with healthcare providers often work with dedicated coding and billing professionals who are well-versed in payer guidelines and can help ensure that documentation is in alignment with the latest requirements. Continuous education and training for healthcare providers are also essential to stay updated on evolving guidelines.

"Because Guidelines are always changing, POL and Reference Toxicology labs have to have documentation for every test that's ordered. If not, they lack documentation & compliance and lose out on revenue due to denied claims." Michael Lu, Cellarian COO

It's important to note that the goal of payer guidelines is to ensure that medical services are provided based on evidence-based practices and that healthcare spending is allocated efficiently. While these guidelines can be challenging to navigate, their intent is to promote appropriate and cost-effective healthcare delivery.

You don't have to do this alone. We can help.

Reach out to info@cellarian.com or call us at (866) 776-6310.