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Tip: Five more keys to monitor medical necessity

Patient Financial Services Weekly Advisor, August 19, 2005

Last week, we discussed that Medicare's medical necessity requirements are often ambiguous and presented five of 10 key steps to verify medical necessity from Timothy P. Blanchard, Esq., partner in the law firm of McDermott Will & Emery LLP in Los Angeles. Here are his final five steps:

1. Document the process.
Fully document the basis for your corrective action (or explain why you took no corrective action). This demonstrates that you have followed your facility's compliance program and acted reasonably under the circumstances.

2. Address conflicts of interest.
Conflict of interest is at the root of almost all large-scale medical necessity cases. Be sure your facility avoids conflict-of-interest situations.

3. Prepare talking points for peer review confidentiality.
Prepare a statement regarding confidentiality in the peer-review process. "I urge you to have these ready, so when the guys show up with a camera-and they want to know why you're not telling them about this evil doctor who's doing these unnecessary services-that you're not standing there thinking, 'It's peer review process. It's covered by privilege.' Have the talking points. Be prepared to explain to the public why it's important. Why it's necessary."

4. Train staff about the risk of falsification.
Hospital medical staff and employees need to know why they cannot change a record after the fact. Stress the importance of avoiding the temptation to change a record that may come under scrutiny. Train staff how to add notes properly, when an addition is necessary.

5. Implement effective ABN processes.
The advance beneficiary notice (ABN) protects your facility because it puts the patient on notice. "If a physician is concerned about giving the patient an ABN, one option is for them to explain the situation to [the compliance officer or auditor] and provide documentation of why it's reasonable and necessary," Blanchard said. "It also gives them an option, in light of the payer's position, to perhaps reevaluate their treatment approach."

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