How many of your medical-necessity denials are preventable? A 12-question check

By HMI LLC

Medical necessity denials are among the most common payer denials and can often be reduced through a few front-end workflows. Although your facility may use a claims scrubber, it typically identifies the issue after the opportunity to obtain a completed ABN has passed.

Answer each question for your facility as it runs today. Medicare is the baseline here; medical-necessity requirements vary by payer and by the patient's policy.

This is a self-check, not an audit. It reflects your answers only. Do not enter patient information anywhere on this page.

In the clinic setting

Do providers and staff have a centralized, easy-to-search resource with current medical-necessity requirements from major payers, particularly Medicare, and do they use it when ordering services?

Yes Partly No

When a patient's condition does not meet medical-necessity criteria, does someone explain why the test is needed, that the payer may deny reimbursement, and how to complete the ABN?

Yes Partly No

Does every ABN your clinic issues include the estimated cost of the test or procedure and the patient's selected option?

Yes Partly No

If a patient declines the ABN and the provider believes the test is still in the patient's best interest, do providers know they may still order it, with the understanding that reimbursement may not be available?

Yes Partly No

In the ancillary department setting

Does the ancillary department review each provider order and confirm that every ordered test has an appropriate diagnosis?

Yes Partly No

Is each test and diagnosis checked against the medical-necessity tool in your EMR, or a facility-maintained, easy-to-search resource, before the service?

Yes Partly No

For each test or procedure that does not meet medical-necessity criteria, does the patient receive an ABN that is completed correctly and includes the estimated cost of each affected service?

Yes Partly No

If a patient refuses a test, does the department contact the provider to decide whether it should still be performed despite the likelihood of nonpayment?

Yes Partly No

Clinical documentation support for documentation gaps

Do your CDI and coding staff work with providers to make sure documentation supports the patient's clinical need for the test or procedure?

Yes Partly No

Does the record include conservative treatment history, test results, and relevant clinical notes that establish medical necessity?

Yes Partly No

Peer-to-peer review

When the record supports the clinical need for the service, does your facility request a peer-to-peer review?

Yes Partly No

Does your team know which of your payers use predetermined documentation criteria to authorize tests and procedures?

Yes Partly No

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