Medical Necessity: Is Current Documentation Practice and Payment Denial Limiting Access to Inpatient Rehabilitation?

Granger CV, Carlin M, Diaz P, Dorval J, Forer S, Kessler C, Melvin JL, Miller LS, Riggs RV, Roberts PMedical necessityis current documentation practice and payment denial limiting access to inpatient rehabilitation?Medical necessity is a legal, not medical, term. Depending on the stakeholderʼs point...

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Bibliographic Details
Published in:	American journal of physical medicine & rehabilitation Vol. 88; no. 9; pp. 755 - 765
Main Authors:	Granger, Carl V, Carlin, Marsha, Diaz, Pedro, Dorval, Jane, Forer, Steve, Kessler, Corby, Melvin, John L, Miller, Lawrence S, Riggs, Richard V, Roberts, Pamela
Format:	Journal Article
Language:	English
Published:	United States Copyright Wolters Kluwer Health, Inc. All rights reserved 01-09-2009
Subjects:	Continuity of Patient Care - economics Continuity of Patient Care - legislation & jurisprudence Humans Medicare - economics Medicare - legislation & jurisprudence Prospective Payment System - economics Prospective Payment System - legislation & jurisprudence Rehabilitation - economics Rehabilitation - legislation & jurisprudence Rehabilitation Centers - economics Rehabilitation Centers - ethics United States United States
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Summary:	Granger CV, Carlin M, Diaz P, Dorval J, Forer S, Kessler C, Melvin JL, Miller LS, Riggs RV, Roberts PMedical necessityis current documentation practice and payment denial limiting access to inpatient rehabilitation?Medical necessity is a legal, not medical, term. Depending on the stakeholderʼs 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 lionʼs 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. Medicareʼs 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?! Thatʼs what I was taught to know!”
Bibliography:	ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 23
ISSN:	0894-9115 1537-7385
DOI:	10.1097/PHM.0b013e3181aa71a8