a hungry girl opens the fridge

Eat When You’re Hungry…

And stop when you’re full.  I’m not a big fan of giving unsolicited nutritional advice. So this blog is not going to have anything to do with food or nutrition. What I would like to discuss is medical necessity and maintenance care.

Most third-party payers (insurance companies and benefit administration groups) will not include maintenance care as a covered benefit. Maintenance care is defined as treatment meant to keep you at your current health level. What they expect from doctors is to treat you for a specific problem and work toward a specific goal, namely, improving your current health status. Headaches are a great way to illustrate this idea. Let’s say you have a headache and you come into the office for treatment. As a result of the treatment, the headache lessens in either intensity or frequency over the course of five visits. All five of these treatments are medically necessary. One week later, you schedule an appointment and you have not had a headache since your last visit. Your goal is to keep the headaches from returning. This visit is considered maintenance care and would not be covered by your insurance company. However, if you have had two less-intense headaches during that same week, but do not currently have one on the day of your visit, we are still treating your headaches, and therefore your visit is medically necessary.

This can be confusing—in both scenarios, you come into the office for treatment and you are not currently in pain. The difference is whether or not you have reached your treatment goal of relieving pain due to headaches. This type of health care actually makes a lot of sense. Treat the problem until the problem is gone and when it’s gone, stop treatment and enjoy your life. Eat when you’re hungry…and stop when you’re full.

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