Medical Necessity Audits

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Question:

Our Medicare carrier has asked for several patient records from our pain center. They say they are conducting a “medical necessity audit”. What does that mean?

Answer:

Most Medicare carriers have a written coverage policy, referred to as a local carrier determination or LCD, that delineates the signs, symptoms, ultrasound findings and more, that must be present to justify coverage of specific types of procedures. These represent the payor’s medical necessity criteria for payment. If you have not followed the coverage criteria to the letter, you may be at risk for a significant repayment. KZA consultants have assisted many practices undergoing these medical necessity audits. Talk to your health care attorney and consider asking a consultant to review your records to identify your risk areas.