American Healthcare Audit Professionals, Inc.

According to Medicare.gov, “Medically Necessary” is defined as “health-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”

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Often, the status of patients at the time of admission or discharge significantly influences the amount and method of reimbursement hospitals receive. Therefore, hospitals have a duty to ensure that admission and discharge policies are updated and reflect current CMS rules.

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Whether the patient enters the facility through the emergency department (ED), endoscopy, cardiac cath lab, surgery, or as a direct admission, it's important to know how a determination is made for outpatient or inpatient status and whether medical necessity is a consideration.

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At American Healthcare Audit Professionals we have experienced Nurse Auditors and Certified Case Managers with extensive clinical background in providing prompt and professional services in conducting Concurrent reviews in determining whether a patient's status is appropriate.