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


Conducted on Wednesday, March 22, 2017
Recorded event now available


This CLE webinar 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.

Description

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.

Outline

  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

Benefits

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?

Faculty

Linda Fotheringill, Co-Founder and Partner
Fotheringill & Wade, Baltimore

Ms. Fotheringill is a nationally recognized expert on denial and appeals management. She successfully assists hospitals across the country in overturning “hopeless” denials and generating millions of dollars in revenue that would otherwise be lost. Ms. Fotheringill has published numerous articles on appeals and payment recovery in hospital case management, hospital access management, and hospital payment and information management. She co-founded the Denial Management Institute, serves on the editorial board of the RAC Monitor, and has provided denial management education for such hospital associations throughout the country.

Sarah Mendiola, Esq.
Fotheringill & Wade, Baltimore

Ms. Mendiola’s work focuses on the appeal of claim denials by the Centers for Medicare and Medicaid (CMS) contractors, commercial insurers and the Maryland Medical Assistance Program. She has experience with both traditional Medicare denials and Medicare Advantage denials. Ms. Mendiola represents clients at Administrative Law Judge hearings and has obtained favorable results for claim denials from Zone Program Integrity Contractor (ZPIC) audits. Ms. Mendiola came to the firm after many years of performing direct patient care as a licensed practical nurse. 


Recordings

CLE On-Demand - Streaming Video

Includes recorded streaming video of full program plus PDF handouts.

On-demand is the only recorded format recognized for CLE credits in DE, IN, KS, LA, MS, NC, OH, OK, SC, TN, VA, WI.

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*Only available for attorneys admitted for more than two years. For OH CLE credits, only programs recorded within the current calendar year are eligible - contact the CLE department for verification.

**NH attendees must self-determine if a program is eligible for credit and self-report their attendance.

CLE On-Demand Video $297.00

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Recorded Event

Includes full event recording plus handouts.

Strafford is an approved provider and self-study CLE credit is available in most states.

AK, AZ, CA, CO, CT, FL, GA, HI, IA, ID, IL, KY, ME, MN, MO, MT, ND, NJ, NM, NY, OR, PA, TN, TX, UT, VT, WA, WV, WY (Note: Some states restrict CLE eligibility based on the age of a program. Refer to our state CLE Map for additional information.)

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DVD (Slide Presentation with Audio) $297.00 plus $9.45 S&H

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Webinar

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Program Materials

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Program Materials

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CLE Credits

Many states grant CLE credits for on-demand streaming audio programs and recorded events. Our programs are pre-approved in many states. Refer to our state CLE map for state-specific information.

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Customer Reviews

The topic was timely and relevant and the speakers were knowledgeable and had excellent delivery.

Susan Leach DeBlasio

Adler Pollock & Sheehan

The program included very informative information on an important subject.

Jamie L. Webb

Baker Manock & Jensen

I appreciated that the program’s content was current and had great speakers.

Yvette Rhodes

Fowler White Boggs

I thought the webinar was great.

Regina Trainor

North Shore LIJ Health System

The content covered was relevant and timely.

Francis LaMorte, MD

Alvarez and Marsal

or call 1-800-926-7926

Health Law Advisory Board

Lowell C. Brown

Partner

Arent Fox

Jennifer L. Evans

Shareholder

Polsinelli

Ryan S. Johnson

Shareholder

Fredrikson & Byron

Gina M. Kastel

Partner

Faegre Baker Daniels

Karen S. Lovitch

Member

Mintz, Levin, Cohn, Ferris, Glovsky and Popeo

David A. Manko

Partner

Rivkin Radler

John J. Miles

Principal

Ober Kaler

C. Elizabeth O'Keeffe

Counsel

Wyatt, Tarrant & Combs

J. Peter Rich

Partner

McDermott Will & Emery

Donald H. Romano

Of Counsel

Foley & Lardner

Judith A. Waltz

Partner

Foley & Lardner

John R. Washlick

Shareholder

Buchanan Ingersoll & Rooney

Jesse A. Witten

Partner

Drinker Biddle & Reath

or call 1-800-926-7926

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