How Can Practices Clearly Differentiate Cosmetic and Medically Necessary Procedures to Avoid Denials?

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Practices can avoid denials by clearly differentiating cosmetic and medically necessary procedures through accurate documentation, proper coding, and transparent patient communication. In specialties like dermatology and plastic surgery, confusion between cosmetic procedures and medically necessary procedures is a leading cause of claim denials and payment disputes. Clear differentiation protects both revenue and compliance. What Is the Difference Between Cosmetic and Medically Necessary Procedures? A cosmetic procedure is performed to improve appearance and is typically not covered by insurance. A medically necessary procedure is performed to diagnose, treat, or manage a medical condition and may qualify for reimbursement. Insurance carriers require clear evidence that a service meets medical necessity criteria before approving payment. Why Do Claims Get Denied When Procedures Are Not Clearly Differentiated? When documentation does not clearly support medical necessit...
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Value-Based Reimbursement in Behavioral Health

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Value-based care is also known as accountable care. A value-based care system is focused on getting value from quality services. Value-based healthcare is a payment system that rewards healthcare providers in accordance with the quality of care provided to their patients. Payments are based on better health for populations and other things, such as cost reduction, which can lead to a focus on preventative care. The benefit of value-based care is a patient in a value-based healthcare model will have fewer doctor’s visits, medical tests, and medical procedures. Additionally, they pay less on medication as their health gradually improves.
BlueCross BlueShield came into the value-based reimbursement arrangement with Value Network. The provider group has 100+ providers in behavioral health care in Western New York.
“This is another step we’re taking to build a behavioral health care model that’s designed to effectively treat the whole person,” said Dr. Thomas Schenk, Senior Vice President, Chief Medical Officer, BlueCross BlueShield of Western New York. “BlueCross BlueShield of Western New York is proud to partner with the region’s leading behavioral health care providers to introduce the first payment model designed to directly enhance quality care for our members with mental health and/or substance use disorder diagnoses.”
If you want to read the complete blog then click below: Value-Based Reimbursement in Behavioral Health
Location: United States

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