Medical Necessity and RAC Audits

By July 30, 2018 Healthcare Law

Medical Necessity and RAC Audits
What is a medical necessity? According to a RAC Auditor (RA), it is something that is justifiably reasonable and necessary according to evidence-based clinical standards of care. According to who? Is this one-size fits all? How is this even possible? If you are not scratching your head right now, then, you must be the auditor applying your rigid rule to my client’s case.
Let’s examine some major areas of confusion:

  1.  Whether the cost of treatment is reasonable considering the patient’s changes of reaching a desired level of relief or functional improvement…this sounds like you are almost hedging on an investment. If you think you’re going to win, then, make the investment? Not really. Let’s revisit the plan of care. If your plan of care mirrors a certain result in most cases, then, this is where you want to be. Are you essentially over-treating a condition that can be cured or managed without the high-cost treatment that you have chosen? That is how you will want to treat this condition.
  2. Whether the treatment will mitigate the patient’s risk of suffering an even worse outcome of the current condition is left untreated. Well, we have a serious problem here. Again, we cannot predict the outcome of a patient’s recovery, but what happens in most cases? You will want to approach this condition with as much research in your plan of care as possible.

If we can draw a conclusion from this article, here it is:  Did you use the lowest cost of medical treatment required to reasonably reach the desired result? If you did, then, your plan of care matches the cost and the outcome.
Medical Necessity and RAC Audits

Ansari Law Firm

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