Enforcement actions relating to a lack of medical necessity

9 minute read

In a climate of shrinking margins, diminishing reimbursement, and frequent denials, healthcare organizations may make efforts to increase the volume of services they provide, especially those that are more profitable. Of course, there are proper and improper ways to do so. One of the improper ways is to perform and bill for medically unnecessary services.

Having requisite medical necessity to provide medical services is a fundamental tenet of healthcare compliance. It is not a new concept for compliance professionals. However, we continue to see settlements related to allegations of a lack of medical necessity. Many other experts have previously provided excellent articles and presentations on the legal aspects of medical necessity as it relates to requirements of federal healthcare programs. This article is not an attempt to provide a legal explanation or strategy for dealing with medical necessity allegations; instead, it is an attempt to report on the types of clinical services that are getting some enforcement attention when it comes to medical necessity.

The key for conscientious compliance professionals is not only to follow up internally within their organizations on the same types of services shared in this article but also to consider what each type of enforcement teaches us about medical necessity mistakes because they can happen with any healthcare service or within any clinical specialty.

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