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 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.
- Appropriate documentation of medical necessity
- Identifying risks
- Understanding government’s legal theories in medical necessity investigations
- Recent cases, legal actions and settlements
- Defenses available to providers
- Best practices for ensuring compliance with regulations
- 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?
Co-Founder and Partner
Fotheringill & Wade
Ms. Fotheringill is a nationally recognized expert on denial and appeals management. She successfully assists hospitals... | Read More
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.Close
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
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.Close