Quinn C
Am J Manag Care. 1997 Jun;3(6):883-8.
The term medical necessity is difficult to define, a problem for insurers who need to clearly describe what is and is not covered in their contracts with subscribers. An unclear, vague definition of medical necessity leaves insurers vulnerable to litigation by subscribers denied care deemed medically unnecessary. To avoid lawsuits, insurers must make every effort to educate their subscribers about their medical coverage, going beyond merely providing a lengthy subscriber handbook. In decisions on medical necessity, medical directors at insurance companies play a key role. They can bolster the insurer's position in denial-of-care cases in numerous ways, including keeping meticulous records, eliminating unreasonable financial incentives, maintaining a claims denial database, and consulting with other insurers to achieve a consensus on medical necessity.
“医疗必要性”这一术语很难定义，这给保险公司带来了难题，因为它们需要在与投保人签订的合同中明确说明哪些属于承保范围，哪些不属于。对医疗必要性的定义不清晰、含糊，会使保险公司容易遭到被拒绝给予被视为医疗上不必要护理的投保人的诉讼。为避免诉讼，保险公司必须竭尽全力就其医疗保险范围对投保人进行教育，而不仅仅是提供一本冗长的投保人手册。在医疗必要性的决策中，保险公司的医疗主管起着关键作用。他们可以通过多种方式加强保险公司在拒绝护理案件中的立场，包括保持详细记录、消除不合理的经济激励措施、维护索赔拒绝数据库，以及与其他保险公司协商以就医疗必要性达成共识。
