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Medical Necessity Documentation, Challenges and Defense

Complying With Federal and State Regulatory Requirements, Demonstrating Reasonable and Necessary Healthcare Services

Recording of a 90-minute CLE webinar with Q&A

This program is included with the Strafford CLE Pass. Click for more information.
This program is included with the Strafford All-Access Pass. Click for more information.

Conducted on Wednesday, March 22, 2017

Recorded event now available

or call 1-800-926-7926

This CLE course will discuss the importance of documenting medical necessity and the potential risks of failing to meet state and federal regulatory requirements, including Medicare and Medicaid reimbursement. The panel will also examine lessons from recent investigations and litigation and offer guidance on ensuring compliance.


In recent years, there has been a sea change in how the government is approaching healthcare investigations and cases. The uptick in quality-based investigations often include claims that services rendered are not medical necessities.

Government agencies often use the False Claims Act to pursue medical necessity allegations. Hospitals are vulnerable to medical necessity denials when physicians and other healthcare providers do not have a clear understanding of the requirements for medical necessity.

Healthcare providers are only to bill for services that are reasonable and necessary for the patient’s diagnosis and treatment. However, hospitals and healthcare providers face complex compliance challenges with regulatory requirements, particularly when there may be inconsistencies among government agencies establishing criteria for medical necessity.

Hospitals, healthcare providers and their counsel must take steps to ensure proper documentation and be prepared to defend against medical necessity allegations.

Listen as our authoritative panel discusses the importance of documentation and complying with the regulatory requirements. The panel will also examine the potential risks to not meeting the requirements and discuss recent investigations and litigation. The panel will offer guidance on ensuring compliance.



  1. Appropriate documentation of medical necessity
  2. Identifying risks
    1. Understanding government’s legal theories in medical necessity investigations
  3. Recent cases, legal actions and settlements
    1. Defenses available to providers
  4. Best practices for ensuring compliance with regulations
    1. Ensuring appropriate documentation


The panel will review these and other key issues:

  • What impact does the medical necessity requirement have on participation in Medicare and Medicaid programs?
  • What theories is the government asserting in medical necessity investigations?
  • What arguments can healthcare counsel put forth in defense of medical necessity?
  • What must healthcare providers and hospitals do to ensure compliance with the regulatory requirement?


Linda Fotheringill
Linda Fotheringill

Co-Founder and Partner
Fotheringill & Wade

Ms. Fotheringill is a nationally recognized expert on denial and appeals management. She successfully assists hospitals...  |  Read More

Sarah Mendiola, Esq.
Sarah Mendiola, Esq.

Fotheringill & Wade

Ms. Mendiola’s work focuses on the appeal of claim denials by the Centers for Medicare and Medicaid (CMS)...  |  Read More

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