Monday, August 13, 2007

'Medical Necessity': will no one free us from this troublesome term?

FROM: Marsha V. Hammond, PhD: Clinical Licensed Psychologist e mail:

TO: Deana Dolan, RN, BS Email:
Jane Plaskie, RN, MS Email:
Nurse Analysts
Division of Medical Assistance
Telephone #: 919-855-4260
FAX #: 919-715-7679


Tara R. Larson, Assistant Director, Clinical Policy and Programs 919 855 4260

August 13, 2007

Hello Ms. Larson, Ms. Plaskie, and Ms. Dolan:

I have a question pertaining to recent trainings on EPSDT as associated with the term 'medical necessity' which, of course, is the lynchpin piece pertaining to the obtaining of mental health services.

In the online power point presentation by Ms. Plaskie and Ms. Dolan, they indicated, as associated with 'medical necessity':

"....Must be listed in the federal law at 42 U.S.C. § 1396d(a) [1905(a) of the Social Security Act]. Must be medically necessary "to correct or ameliorate a defect, physical or mental illness, or a condition [health problem] identified by screening...'ameliorate' means to improve or maintain the recipient's health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.....must be determined to be medical in nature....."

I do not understand how 'medical necessity' is associated with mental health challenges---IF mental health challenges are (assumed to be) 'medical in nature.' Therefore I do not understand how 'medical necessity' is deemed by DHHS to be the background lynchpin piece associated with mental health services.

'Medical Necessity' is associated with medical problems e.g., lab work; x-rays; CAT scans; medications.

This may seem to be a silly point but when Ms. Larson indicated in her EPSDT presentation in Asheville, NC, last week, and she was queried as to where on the DHHS website was the 'definition' of 'medical necessity' she indicated it was not present. And so, we have a free-floating power point presentation presented by some people associated with DHHS which is untethered to the DHHS web page. If its on the web page as pertaining to mental health services, could I please have the URL?

I am not trusting of an agency that puts forward this notion of 'medical necessity' but is willing to run through the mill the Endorsed Provider agencies when the doctoral level psychologist, or psychiatrist, has been asked to sign off re: 'medical necessity' but then is told that it is not medically necessary as associated with a set of criteria that for all purposes is INVISIBLE.

As a provider, I sign off on the PCP forms in order to indicate that Community Support, for instance, is 'medically necessary'. However, my signature and opinion matters not. I am not allowed as the doctoral level psychologist to seek out more than 12 hrs/ week/ client of Community Support services unless I want to be flogged with a post-payment review and associated with that---it is entirelly possible my company would have to pay back any monies earned for hours greater than 12 hrs/ week/ client. It does not matter that I may deem it to be 'medically necessary' utilizing your criteria, namely: "'ameliorate' means to improve or maintain the recipient's health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems."
To my mind,something has to give: either you get another term; or you redefine 'medical necessity' so that it includes mental health treatment; or you allow the demanded doctoral level signatory to do their work; or, you just let anyone sign the 'medical necessity' Person Centered Plan.

DHHS continues to create massive confusion with these various sets of information which confuses providers and certainly will obtain the (assumably) desired results: No Community Support of greater than 12 hrs/ week/ client is acceptable. And no Endorsed Provider agency is going to continue to provide services while the matter is appealed because no one can afford to pay back such massive amounts of money come post payment review. And no Medicaid Appeal is in place. And no attorneys are there to challenge this entire matter.

I am looking forward to you providing me some clarification re: this matter of just how does 'medical necessity' overlap with mental health services.


Marsha V. Hammond, PhD: Licensed Psychologist, NC


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