This session provides a review and update of legal issues of special importance to PA/LTC medicine providers participating in Medicare and Medicaid. The speakers will discuss key legal issues and concepts, and will guide the participants to develop and practice an approach to evaluating cases as part of ongoing quality assurance and compliance activities. This session will focus on the issues of medical necessity, false claims, and worthless care. The history and philosophy of these concepts and their application to PA/LTC settings will be discussed, along with illustrative cases, which participants will evaluate together.
Review the concepts of 'medical necessity', 'false claims', and 'worthless care', and their relationship to quality of care.
Apply the concepts of “medical necessity”, “false claims”, and “worthless care”, and their relationship to quality of care to specific case examples to evaluate medical necessity and quality of care in individual cases.
Describe the processes by which CMS and other government-related entities evaluate 'medical necessity', potentially 'false claims', and potentially 'worthless care' in PA/LTC settings, what SNFs and other providers do in response, and develop strategies for how PA/LTC practitioners and Medical Directors may be asked to participate productively in these processes to provide clinical insight and interpretation and help to resolve concerns.
Discuss proactive strategies that will empower the physician/Medical Director to provide quality care to the patients at the SNF, assist the facility to be successful in the current increasingly challenging health care environment and assist the facility team to avoid – and successfully to refute if/when necessary – any unfounded allegation from any source of providing “worthless care” or of faling to meet the requirements of medical necessity.