Up to 30% of all procedures and tests that are prescribed to patients can be considered unnecessary or overkill. This is 30% of overall medical spending, not just Medicare! Since Medicare pays for healthcare for elderly people, and these people are one of the most prescribed and tested demographics, it can be assumed the Medicare is paying for many tests and procedures that are not proven or evidence based.
The American Medical Association defines medical necessity as: “Healthcare services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site, and duration; and (c) not primarily for the economic benefit of the health plans and purchasers or for the convenience of the patient, treating physician, or other healthcare provider.”
Any service that do not fall into this definition should be considered unnecessary and not be billed to Medicare or any insurance company for that matter. However, this leaves lots of space for interpretation between healthcare providers, insurance companies and the public. Most experts agree that in this grey area of interpretation is often where the unnecessary procedures are found. It is difficult to keep up on new procedures and techniques, so it is hard to differentiate between necessary and unnecessary procedures, since every case is different and it is hard to contradict a doctor’s opinion.
So what does this mean for Medicare and the healthcare system? It is important to document procedures and to educate physicians about avoiding over-treatment, so that in the long run, Medicare can become more efficient.