Medical Necessity: Clinical Medical Necessity vs Billing Medical Necessity

Overview: The session will provide an overview of medical necessity, particularly for the point of view of billing medical necessity as opposed to clinical medical necessity. We will address what providers and hospitals can do to try to stem this enforcement effort and how compliance programs should be adapted to address this risk area. We will address how historic fraud and abuse detection efforts are changing and review what the future holds for fraud detection and enforcement.

We will discuss how companies/hospitals should self assess medical necessity activity. We will address who is accountable for the medical decisions of physicians and what should be done to fulfill that responsibility. We will provide insight into measurement tools that allow hospitals to evaluate and/or challenge the medical decisions of the medical staff. We will also discuss how hospitals can self assess medical necessity activity. The roll of peer review and due diligence reviews will be reviewed.Finally, the webinar will review some of the high-profile cases and how the government is approaching its enforcement activities.

Why should you attend: This session is designed for health care executives, physicians and other health care providers who participate in and receive remuneration from Medicare, Medicaid, and other federal health care programs such as TriCare. Several recent actions bring home the realization that medical necessity is an enforcement target and compliance focus should be a priority.

As a health care executive, physician or other health care provider, you should be very concerned about the potential for the government to use medical necessity as a basis to pursue a federal False Claims Act action to stem the tide of overutilization of Medicare, Medicaid, TriCare and other government healthcare services. Three cases in particular, involving spinal surgery, have occurred in the past year. In at least one of those cases, the surgeon has apparently left the country for his native Pakistan. Attend this webinar and learn how to protect yourself and your organization.

Areas Covered in the Session:

• Medical necessity: clinical vs billing necessity
• How compliance programs can be adapted to address this risk area
• Enforcement activities involving medical necessity
• Self assessment
• Accountability for medical decisions
• Measurement tools
• The roll of peer review
• High-profile cases

Who Will Benefit:

• CEOs
• COOs
• CNOs
• CMOs
• Medical Staff Officers
• Physicians
• Physicians who serve on peer review committees
• Medical Staff
• Support Staff
• Attorneys representing Medical Staffs

William Mack Copeland MS, JD, PhD, LFACHE, practices health care law in Cincinnati at the firm of Copeland Law, LLC. He is also president of Executive & Managerial Development Group, a consulting entity providing compliance and other fraud and abuse related services. A graduate of Northern Kentucky University Salmon P. Chase College of Law, Bill is a frequent author and speaker on health law topics.

Copeland is a member of the American Health Lawyers Association, American, Ohio and Cincinnati Bar Associations and is a life fellow in the American College of Healthcare Executives. He was awarded the American College of Health Care Executives Senior-Level Healthcare Executive Regent’s Award in 2007.

MentorHealthPhone No: 800-385-1607FaX: 302-288-6884 webinars@mentorhealth.comEvent Link: http://bit.ly/1fAxM73http://www.mentorhealth.com/

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