Articles

Problem

Denials and refund demands due to the failure to have a treatment plan (Care Plan) documented in the chart.

Subjective History

Over the years, Medicare and others have paid claims based on the information that was only on the claim form. Supporting clinical necessity details from the charts were rarely used.

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By Dr. Jeff Brown -Meaningful Use Mentor

Technological advancement enhances the success of any industry, and healthcare is no exception. It is easy to recognize technology’s role in the medical world—magnetic resonance imaging and arthroscopic surgery (necessary or not) are two great examples. It’s also easy to understand the reason for such improvement...would you like to have a 1950s knee surgery based on a 1950s x-ray in 2012?

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The Centers for Medicare and Medicaid (CMS) requires that all treatments it pays for be medically necessary. CMS normally reimburses fairly quickly, then audits submitted claims to detect cases where treatment should not have been authorized. Doctors demonstrate the medical necessity of their claims by submitting, when requested, the documentation on cases that the auditors have flagged. If submitted documentation justifies the treatments paid for, the claim will be upheld. If not, then the government asks for its money back, and fines may be imposed.

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by Rick Lehtinen
Aug 10, 2011

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Question: 
March 12, 2014

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