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.


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, 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. 


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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.

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Customer Reviews

I liked the use of current court cases.

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Northwestern Memorial Hopsital

Well done ---

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The content covered was relevant and timely.

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Health Law Advisory Board

Lowell C. Brown


Arent Fox

Jennifer L. Evans



Ryan S. Johnson


Fredrikson & Byron

Gina M. Kastel


Faegre Baker Daniels

Karen S. Lovitch


Mintz, Levin, Cohn, Ferris, Glovsky and Popeo

David A. Manko


Proskauer Rose

John J. Miles

Senior Counsel

Baker Donelson

C. Elizabeth O'Keeffe


Wyatt, Tarrant & Combs

J. Peter Rich


McDermott Will & Emery

Donald H. Romano

Of Counsel

Foley & Lardner

Judith A. Waltz


Foley & Lardner

John R. Washlick


Buchanan Ingersoll & Rooney

Jesse A. Witten


Drinker Biddle & Reath

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