This article was recently posted by Glenn Kraus on HCPRO's CASE MANGEMENT WEEKLY. With his permission, it is essential reading for HCM leaders. It highlights the reasons why the UR function can no longer be an 'add on' activity to the hospital case managers' role. Executives lax attention to the issues surrounding 'medical necessity' is no longer realistic if the hospital wants to financially thrive.
Designing and executing a clinical resource management program is not easy. It’s not so much that any one part of the program is difficult to design and implement. Rather, it’s the combination of all the parts that becomes untenable.
When we started this newsletter back in 1994, we reported the difficulties in obtaining information about payer denials. Hospitals simply could not provide actionable information to identify the source of their denials...
When case management was introduced in hospitals in the mid 80s, it was accompanied by a promise to control costs at the bedside.
GOING BEYOND THE COMMON MEDICAL NECESSITY THOUGHT PROCESS
Posted By Glenn Krauss On March 21, 2011
Many case management professionals are familiar with Title XVIII the Social Security Act, 42 U.S.C. 1395 section 1862 (a)(1)(a), which states:
No Payment may be made under Part A or Part B for any expenses incurred for 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.
Most healthcare professionals consider a service medically necessary if it:
However, medical necessity acquires new meaning in the context of recent Medicare Administrative Contractor (MAC), Recovery Audit Contractor (RAC) and CERT denials of clinical scenarios that at face value appear reasonable and necessary. Contractors are denying services because physician documentation did not meet reasonable standards to perform the procedures.
Transforaminal epidural injection denials
Special Edition MLN Matters article SE1102 cites “Inappropriate Medicare Payments for Transforaminal Epidural Injection Services,” an August 2010 OIG report. The OIG analyzed a random sample of 433 records involving transforaminal epidural injection services provided in 2007 and found that 34% of transforaminal epidural injection allowed by Medicare didn’t meet Medicare documentation requirements.
Local Coverage Determination L30481, which governs transforaminal injections, states that documentation must meet the following requirements:
Other documentation errors highlighted in the OIG report include the following:
Other notable denials
Highmark Medicare Services, the region 12 Medicare Administrative Contractor (MAC), issued a notice summarizing denials for certain Medicare services from October to December 2010. Access this notice at https://www.highmarkmedicareservices.com/cert/errors/pdf/a-cert-oct-dec-10.pdf .
The following denials and rationales are noteworthy from a case management perspective:
Due to continued RAC, CERT, and MAC related medical necessity denials associated with pacemaker insertions, CMS developed a CERT Fact Sheet reiterating documentation requirements associated with pacemaker insertion. I encourage you to read it to help reduce medical necessity denials for pacemaker insertions, which are costly.
Read the fact sheet at http://www.cms.gov/MLNProducts/downloads/CERT_Pmaker_FactSheet_ICN905144.pdf .
I also call your attention to the recent article released by Noridian Administrative Services, LLC, “Submitting Documentation to Support Procedures Billed.” Access this article at https://www.noridianmedicare.com/cgi-bin/coranto/viewnews.cgi%3fid=EkAAZAFZpyiTClLXNh&tmpl=part_a_viewnews&style=part_ab_viewnews .
Putting medical necessity in proper perspective
Medicare provides a general definition of medical necessity that embraces the concept of reasonable and necessary, it issues LCDs and NCDs that establish covered diagnoses and it instructs Medicare contractors to apply screening criteria when reviewing claims. The onus is on providers to ensure complete and accurate clinical documentation that supports medical necessity.
Providers must do more than ensure that diagnosis supports medical necessity and document whether an inpatient or outpatient setting is appropriate. Clinical documentation must reflect a physician’s clinical judgment, rationale, and medical decision-making for recommending a procedure for a patient. Documentation also must include the following:
The H&P often is nothing more than a completed from supplied by the primary care physician or consulting medicine physician who cleared the patient for surgery. This does not establish medical necessity for the performance of the procedure, regardless of patient status designation.
Case management professionals can and should work with clinical documentation improvement specialists to affect positive change in physician patterns of clinical documentation.
Welcome to the May issue REFLECTIONS. This month we introduce our readers to the 'knowledge worker,' a term coined by management guru Peter Drucker almost 50 years ago. He presciently predicted that employees of the future will be be contributing information that materially affects the capacity of the organization to perform and to obtain results. He could have been speaking about the future hospital case manager. As always, we welcome your comments.
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"Thank you for a well organized, detailed, and comprehensive book. I appreciate that you took the time to put your knowledge and experience in writing."Deonna Villegas-McPetersCommunity Regional Medical CenterFresno, CA