How are the RACs winning “medical necessity” challenges?
A. Legally, the RACs can’t break new ground with their medical necessity arguments in order to uphold denials. However, there is a broad and well-established foundation of CMS Payment Criteria (based primarily around evidence-based outcomes) and regulatory / legislative documentation to support the vast majority of RAC audit overpayment determinations (i.e. NCDs, LCDs, QIO guidance, etc.). The following was extracted from a CMS Quality Improvement Organization medical review audit tool: Criteria Application vs. Medical Judgment – The care setting decision and treatment plan should be based on the patient’s clinical condition and the services required to address that condition. Physicians should use their own best medical judgment in determining the appropriate care setting and services required based upon the applicable, evidence-based standard of care for the patient’s clinical condition. The bottom line – Medicare isn’t using evidence-based outcomes and clinical payment criteria to d
