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Medical Necessity: It’s a Necessity

by admin on September 14, 2016 2 comments

medical necessityBy: Jacqueline Bain

Recently, a Florida-based physician practice specializing in pain management was ordered to pay the Federal Government $7.4 after it was determined that the group’s physicians were ordering medically unnecessary drug screens and billing Medicare for those tests. Federal prosecutors contended that the group’s physicians had appropriately ordered initial drug screens on many patients, but had inappropriately ordered more extensive (and more expensive) follow up tests nearly 100% of the time. Moreover, patient medical records did not reflect the need for more extensive testing.

Appropriate documentation in a patient’s medical record is crucial for many reasons:

  1. Medical records are often used by other treating providers to treat the patient for other reasons. If a record is incomplete or absent, another treating provider will not be fully informed when treating the patient.
  2. Insurance companies often and increasingly request substantiation of tests run or scripts written. Without adequate documentation from the treating professional in the record, these tests and scripts are nearly impossible to defend.
  3. Federal and State investigators and regulators are increasingly looking into allegations of healthcare fraud made by both government payors and commercial payors. Defenses are much more difficult to mount in the absence of documentation in the record of why the treating provider did what s/he did and why.

So what is required for medical necessity documentation? In short, the healthcare item or service ordered must be reasonable and necessary for the diagnosis or treatment of the patient’s illness or injury. Moreover, a patient’s medical record must adequately support payment for the services billed. Comprehensive documentation is key. At a minimum, medical records should include the following: the signs or symptoms exhibited by the patient and the need for additional tests or prescriptions based on those signs and symptoms.  Without that information, the record is incomplete.

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