Limiting Retroactive Demands for Medical Necessity Documentation
The US District Court recently issued a ruling limiting the latitude Medicare carriers have in requiring providers to "second guess" referring physician's medical opinions and advise beneficiaries that services may be denied as not medically necessary. This is the first, but probably not the last, legal precedent to be set in response to the many legal proceedings regarding Medicare coverage for powered wheelchairs and similar mobility aids.
CIGNA retroactively denied the medical necessity for motorized wheelchairs on the basis that medical necessity was not properly established, even though CIGNA had approved and paid the claims based on Certificates of Medical Necessity provided by the patients' physicians. They also demanded immediate return of the half million dollars Medicare had paid and ordered the provider to allow the patients to keep the chairs since "they should have known that Medicare would deny this care" but failed to obtain a signed waiver prior to delivery. Medicare's internal appeals process upheld CIGNA's decision.
The provider then sued in District Court and prevailed. The court ruled that the law did not require suppliers to obtain and keep patient's private medical records, or to second-guess physicians by making independent medical necessity judgments so as to advise patients that Medicare might deny payment. This is an interesting decision because it seems to reduce the steady increase in the "reimbursement roulette" nature of Medicare payments, which has intensified recently as the frequency of post-payment reviews and audits has skyrocketed.
The full opinion is very interesting reading, and can be downloaded at U.S. District Court documents.
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