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Medical Fraud or Medical Necessity: Documenting Your Story

Gain an understanding of medical necessity and the importance of correct documentation.

The difference between the government making a determination of medical fraud as opposed to medical necessity lies in your documentation. Physicians, hospitals, labs, long-term care providers, and all other medical providers must properly document that their services were medically necessary. This course will inform providers, compliance professionals, and billers of the meaning and interpretation of the term medical necessity. The course will also provide guidance for properly documenting the procedures and services performed. To better understand the impact of proper documentation of medical necessity, this material will focus on recent government prosecutions and settlements, particularly in areas of increased government focus, such as telehealth services. Gain practical tips and considerations for documenting medical necessity.

68 minutes
Course Exam
Certificate of Completion
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Over 35 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

Agenda

The Definition and Application of the Term Medical Necessity

  • Medical Necessity as Defined by CMS
  • Medical Necessity as Defined by States
  • Medical Necessity as Defined by the Courts

Appropriately Documenting Medical Necessity

  • Document Type, Frequency, Extent, and Duration
  • Standards of Practice
  • Evaluation and Diagnosis Codes

Lessons Learned From Recent Government Prosecutions

  • Overview of Recent Cases
  • Potential Defenses

Practical Considerations

  • Policies
  • Internal Audits
  • Results: Effective Communication, Correct and Timely Reimbursement, and Patient Safety
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Why Lorman?

Over 35 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

Credits

OnDemand Course

This course was last revised on April 20, 2022.

Call 1-866-352-9540 for further credit information.

  • AHIMA 1.0 including Data Structure, Content, and Information Governance 1
     
  • This program has been approved for 1.0 continuing education units for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting prior approval from AHIMA does not constitute endorsement of the program content or its program sponsor.
     

This program does NOT qualify, nor meet the National Standard for NASBA accreditation.

MP3 Download

This program does NOT qualify, nor meet the National Standard for NASBA accreditation.

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Why Lorman?

Over 35 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

Faculty

Theresa DeAngelis

Theresa DeAngelis

Quarles & Brady

  • Associate, Healthcare Law Group, Quarles & Brady LLP
  • Advises health care industry clients on a wide range of regulatory, transactional, and litigation matters, with a primary focus on fraud and abuse compliance and litigation
  • Experience in government investigations
  • Previously represented qui tam relators under federal and state False Claims Acts in health care matters, both in cases in which the government elected to intervene and cases in which the government declined to intervene
  • Master’s degree in health administration
Kirti V. Reddy

Kirti V. Reddy

Quarles & Brady

  • Partner, Healthcare Law Group, Quarles & Brady LLP
  • Extensive experience in government investigations and federal civil litigation
  • Advises on fraud and abuse matters and conducts internal investigations and risk assessments
  • Former Assistant United States Attorney for the Southern District of New York, Civil Division
  • Previously lead counsel for the government on a number of investigations and prosecutions involving health care matters
  • Executive Office for the United States Attorney’s Director’s Award, Superior Performance for investigation and litigation of a matter based on the False Claims Act, 201
  • Adjunct Professor, Seton Hall Law School
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Over 35 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

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Product ID: 409563
Published 2022
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