What is the potential outcome if services are not deemed medically necessary by insurers?

When insurers determine that services are not medically necessary, the potential outcome is that claims for those services may be denied altogether. This decision stems from the principle that insurance is designed to cover only services deemed necessary for the diagnosis or treatment of a health condition. If a service does not meet this criterion, it lacks justification for coverage under the policy terms, leading insurers to deny payment for those services.

Insurers have strict guidelines and criteria to assess the medical necessity of services, which typically include clinical evaluations, established medical guidelines, and the specific coverage policies of the insurer. When a claim is submitted for services that are assessed and determined not to be medically necessary, it fails to pass the examination for reimbursement, which results in a total denial of the claim. Thus, understanding the intricacies of what constitutes medical necessity is crucial for coding specialists, as it directly impacts the financial outcome of submitted claims. The other options, such as expediting claims or placing them on hold, pertain to different circumstances and do not apply when services are classified as non-essential by the insurer.