Question

WHO Determine MEDICAL necessity? Ann Baker, a 45-year-old

accountant, has been a member of a national health maintenance
organization (HMO) for 20 years. She has obtained care from the HMO
primary car

Answer 1

Medical necessity is determined by healthcare providers, insurance companies, and government agencies based on established guidelines and criteria. Factors considered include the patient's condition, treatment options, and coverage policies.

Step-by-step explanation:

Medical necessity is determined by various entities in the healthcare system. These entities include healthcare providers, insurance companies, and government agencies. The determination of medical necessity is based on established guidelines and criteria set by these entities.

Healthcare providers, such as doctors and specialists, assess the patient's condition and treatment options to determine if a particular medical service or procedure is necessary. They consider factors such as the patient's symptoms, medical history, and the expected benefits and risks of the treatment.

Insurance companies review medical claims and evaluate whether the services or procedures meet their coverage criteria for medical necessity. They have their own guidelines and policies that help determine the medical necessity of a particular service or procedure.

Government agencies, such as Medicare and Medicaid, also play a role in determining medical necessity. They establish guidelines and coverage criteria for the services they provide or reimburse.