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Tip: Five keys to monitor medical necessity

Patient Financial Services Weekly Advisor, August 12, 2005

Five keys to monitor medical necessity

Medicare's medical necessity requirements are often ambiguous, so when you're verifying medical necessity at your facility, follow these steps--the first five of 10--recommended by Timothy P. Blanchard, Esq., partner in the law firm of McDermott Will & Emery LLP in Los Angeles:

1. Follow OIG hospital guidance. Start with a risk assessment, and pay close attention to major surgical and medical procedures.

2. Review your policy. Verify that your facility has a strong policy-you'll be glad you have one when a problem arises. "You want to be deciding policy in the abstract, not with respect to a particular physician at a particular time," Blanchard says.

3. Publicize procedures. Let the medical staff know how your facility handles medical necessity. Physicians need to be aware that when you get a complaint about medical necessity, the organization will investigate independent of the medical-staff process.

4. Be consistent. Every physician should receive the same treatment, regardless of status or the number of referrals he or she makes.

5. Respond promptly to documentation requests. Whether a payer, the OIG, or the program-integrity group makes a documentation request, complete it as quickly as possible.

Coming next week: Blanchard's last five tips to monitor medical necessity.

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