Regulating Medical Necessity Decision Making By Health Maintenance Organizations

Singer, S., et al.

Medical necessity and external review have become subjects of regulatory and legislative attention. National surveys of regulators and managed care plan medical directors provide a map of regulatory oversight in these areas, information about the influence of state external review regulation on health maintenance organizations, and insight into differences in opinion between these key stakeholders.  Results show significant variation and clear differences between regulators and medical directors.  Regulators concern themselves primarily with the decision-making process while plans focus more on clinical practice and on the scientific evidence in support of or against particular medical necessity judgements.  Results suggest that better communication between regulators and medical directors could improve policies and compliance.