How Compliance Officers Can Prevent Multi-Million Dollar Lawsuits by Educating Physicians on Medical Necessity

Medical necessity matters. The concept of medical necessity (or lack thereof) is what drives much of the multi-million dollar whistleblower suits and healthcare provider settlements we see in the healthcare industry today. Corporate integrity agreements often spell out requirements placed on providers who made missteps when it came to medical necessity.

However, it seems like nobody can agree on exactly what is medically necessary. Did Bob really need that nephrectomy? Doctors, compliance officers, coders, billers and government enforcement agencies all agree that Medical Necessity must exist before clinical services are provided, billed and reimbursed. But, the second someone tries to declare something is, or is not medically necessary, everyone involved will often disagree on how to define medical necessity or how to determine if it existed for clinical services that were provided and reimbursed.

By law (section 1862 of title XVIII of the Social Security Act), the Medicare program can’t make any payment under Part A or Part B for any items or services that “are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”

Medically unnecessary care:

• Puts patients’ safety at risk during procedures and treatments that are truly not needed
• Puts healthcare providers in the crosshairs of enforcement agencies
• Causes over-utilization of already scarce healthcare resources
• Is a clinical determination that is approached differently by different perspectives (e.g., payer vs. provider)

Physicians, and other clinicians in particular, have strong opinions on common questions surrounding the topic. How should you approach and discuss the sometimes sensitive topic of medical necessity with physicians? How can you respectfully and effectively provide physicians with medical necessity compliance training?

Watch our on-demand webinar, How To Communicate Medical Necessity with Your Physicians, to answer these and other questions about medical necessity and physicians.