Medical necessity: is current documentation practice and payment denial limiting access to inpatient rehabilitation?
Medical necessity is a legal, not medical, term. Depending on the stakeholder's point of view, it may seem less about human need and dispensing medical care and more about a web of rules, rulings, regulations, and manuals, especially for Medicare patients, who use the lion's share of rehabilitation services. In other words, the term medical necessity seems, to some stakeholders, to refer more to what determines payment by Medicare instead of what should be done to determine optimal patient health. Such a perspective on medical necessity has major implications, considering that Medicare pays for most of the rehabilitation treatment in some 1200 inpatient rehabilitation facilities and that its policies determine which patients qualify for admission to an inpatient rehabilitation facility. Medicare's medical necessity policies are often described by inpatient rehabilitation facility administrators and physiatrists as complicated and unfair, as well as being demeaning to the standing of physicians. Ask some physiatrists about their patients meeting Medicare guidelines for medical necessity, and they might bark, "Medical necessity?! That's what I was taught to know!"
Granger
Carl V
CV
Department of Rehabilitation Medicine, School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Amherst, NY 14228, USA.
Carlin
Marsha
M
Diaz
Pedro
P
Dorval
Jane
J
Forer
Steve
S
Kessler
Corby
C
Melvin
John L
JL
Miller
Lawrence S
LS
Riggs
Richard V
RV
Roberts
Pamela
P
D003266:Continuity of Patient Care / Q000191:economics / Q000331:legislation & jurisprudence; D006801:Humans; D006278:Medicare / Q000191:economics* / Q000331:legislation & jurisprudence; D011445:Prospective Payment System / Q000191:economics / Q000331:legislation & jurisprudence; D012046:Rehabilitation / Q000191:economics* / Q000331:legislation & jurisprudence; D012047:Rehabilitation Centers / Q000191:economics* / Q000941:ethics*; D014481:United States