Sunday, September 28, 2008

In support of an expanded vision of 'medical necessity', more in keeping w/ mental health needs, distinctly NOT NC DHHS's 'rehabilitation' model

The term 'medical necessity' is linked to the authorization of both physical and mental health services. It is deemed to be necessary in order to create services.

Why is an understanding of the term important? Because it can be used as a reason to deny services.

What is the problem w/ NC DHHS's 'rehabilitation model' which is based on medical services authorization?

It does not take into account the common chronicity of mental health issues.

The below attempts to outline an expanded definition of 'medical necessity' more in keeping with the usual trajectory of mental health issues.

The brain is not an organ that can be taken out and repaired like your hip can be replaced or your cancer removed.


The National Psychologist September/ October 2008, p. 9, article, entitled:
'Data Mining Programs' intensify scrutiny of Medicare claims', by Paula E. Hartman-Stein, PhD, states:

"The definition of medical necessity used by CMS is "services or items reasonable and necessary for the diagnosis of treatment of illness or injury or to improve the malfunctioning of a malformed body part." Georgolulakis said when a patient reaches a point where further improvement does not appear to be indicated or there is little expectation of improvement, the services are no longer considered reasonable or necessary."



"Medical necessity is a United States legal doctrine, related to activities which may be justified as reasonable, necessary, and/or appropriate...."

Tony Puente, PhD, Neuropsychologist based in Wilmington, NC, stated at APA, 2008, Boston: "Medical necessity is whatever your contract says it is."

The National Psychologist author contributed this:

"According to Georgoulakis, mental health may be an easy target for the Recovery Audit Contractor (of Medicare) program because the criteria for medical necessity is not as straightforward to pionpoint compared to physical medicine. Medical necessity MUST BE SUPPORTED by the patient's progress in therapy and a plan with clearly identified goals. "In mental health if we're not doing treatment plan revisions every 30-60-90 days we can really get nailed." .....

He said the clinical record should document target symptoms, goals of therapy, methods of monitoring outcome and how the treatment is expected to imrpvoe the health status or functioning of the patient."

Vicki Gottlich, J.D., L.L.M., of Washington D.C.'s Center for Medicare Advocacy stated, in an overviewing of how Medicare works well----or not---for people having chronic illnesses (Jaunary, 2003:
MedNec1202.pdf; pgs 3,4)

"Medicare standards for making medical necessesity determinations in individual cases do not always address the particular needs of beneficiaries with chronic illnesses....for certain services such as outpatient therapy, Medicare policies impose improvement standards that are inconsistent with the statutue.....
Medicare policiers concerning medical necessity determinations in individual claims should be revised to recognize that the overwhelming majority of beneficiaries have at least one chronic condition whose method of treatment and treatment goals are different from the method of treatment and treatment goal for acute illness or injury.....maintenance of abilitry, prevention of deterioration, and patient education should be erecognized as treatment goals for beneficiaries with chronic conditions."


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