Medical Necessity Review

Our reviews evaluate the complete medical record to validate the medical necessity for providing a specific service. Additionally, we assess the documentation to determine the appropriate site of service (inpatient vs. outpatient) for the procedures performed. Facilities may request reviews to evaluate individual physicians with a comparison to their peers. These reviews are often prompted by the OIG work plan and are the current focus of RAC audits.

ZHealth offers three types of medical necessity reviews: Procedure Medical Necessity, Inpatient Medical Necessity, and Medical Necessity based on Imaging Studies. Deliverables include a comprehensive report with a formal presentation of findings and recommendations by a ZHealth physician on-site or by phone.

In this high-risk area targeted by the OIG, RAC auditors, and Medicare, stay compliant with documentation requirements for medical necessity in order to get appropriately reimbursed. Contact us today.


  • Our physicians determine if the documentation supports the required medical necessity for performing the procedure

  • We determine if the acuity of care required for inpatient admission is validated by the documentation

  • We review actual procedure images to evaluate the accuracy of the physician's documented findings