Revenue Cycle Risks: Insights from the DOJ for Mastering Medical Necessity


Medical necessity is the overarching driver for reimbursement of healthcare services. Using Medicare and the law as an example, the Social Security Act states: 

“No payment may be made under Part A or Part B for any expenses incurred for items or services not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” 

This portion of the law is often cited when financial settlements result from allegations of medically unnecessary services. Having success in medical necessity requires a team effort from everyone involved in the revenue cycle. In this webinar, we’ll examine three instances of revenue cycle woes related to medical necessity, or the lack thereof. Outcomes from studying these case studies will include: 

  • Discover clinical services government agencies such as HHS OIG, U.S. DOJ and Medicare are scrutinizing the most in regard to medically necessity 

  • Learn the role of pre-visit revenue cycle work that needs to be performed even before the patient arrives for a service 

  • Explore the tools necessary to understand key medical necessity requirements and payer policies 

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