The idea of providing health care treatments and insurance coverage according to “medical necessity” determinations seems eminently reasonable. Its obvious ethical thrust is to discourage unnecessary, wasteful or fraudulent practices. As practically implemented, however, “medical necessity” regulations and determinations have proven remarkably controversial and have particularly vexed rehabilitation providers. Medical necessity determinations incur problems as to who should ultimately make them: payors, health providers or the courts. Obviously, whoever controls the definition of medical necessity controls the flow of health care dollars. While ethical theory can offer important insights about our moral obligations, it remains unable to reliably translate its theoretical principles and rules bearing on harms, benefits and justice into informing medical necessity determinations. Thus, resolving disputes over medical necessity have taken a procedural approach that looks to the interpretation of contractual language in insurance policies, often at the bench of an administrative law judge.
Objectives: Upon completion of this course, the participant will be able to:
1. Describe some recent history of medical necessity determinations, as that history has played out among insurance companies, health professionals and the courts;
2. Explain why medical necessity determinations can be vexatious and controversial;
3. Describe the kinds of conflicts of interest in making medical necessity determinations confronting payors and providers of care
4. List current methods of resolving conflicts and disputes over medical necessity determinations and their limits. Identify cultural dimensions of outcome studies
5. Explain how values bearing on success probability and cost affect our interpretation of outcomes
6. Discuss the role of evidence in interpreting outcome studies
Physical Therapist, Occupational Therapist, Physical Therapy Assistance, Occupational Therapy Assistance and Speech Therapists and healthcare professionals.
PT CEU’s: Motivations Inc is an approved provider of Physical Therapy continuing education by these professional bodies: Texas Chapter of the American Physical Therapy Association, ILDPR- Illinois Department of Professional Regulation Approved PT CE Sponsor, NY- New York State Education Department, Office of the Professions, Physical Therapy Board of California. Many state boards recognize these for pre-approval purposes. Contact us if you would like verification for your state.
OT CEU’s: Motivations, Inc. is an approved CEU provider by AOTA. This course is approved for distance learning: interactive. ATC CEU’s: Motivations, Inc. is an approved CEU provider by NATA BOC. ASHA CEU’s: Motivations, Inc. is an approved CEU provider by ASHA. This course is offered for 0.2 ASHA CEUs (Intermediate level, Related area).
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