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What is Medical Necessity?

By Robert David, Esq.

The term ?medically necessary? in the context of Medicare and Medicaid reimbursement has been under some scrutiny lately. Medicare defines "medical necessity" as services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Medicaid has a similar definition. For items or services where there is no specific limitation based upon a coverage policy, medical necessity has often been left to the good faith determination of a physician. However, in several prosecutions of physicians for infusion of HIV drugs, the government has relied on fraudulent diagnosis or unnecessary prescribing of medications as a basis of prosecution, citing to the physician motive of profit over appropriate patient care...continue to full post

Full post as published by Health Care Fraud Blog on April 28, 2009 (boomark / email).