Physicians/ Doctors

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    Physician Liability for DMEPOS Medical Necessity

    The Medicare program only pays for health care services that are medically necessary. In determining what services are medically necessary, Medicare primarily relies on the professional judgment of the beneficiary’s treating physician, since he or she knows the patient’s history and makes critical decisions, such as admitting the patient to the hospital; ordering tests, drugs, and treatments; and determining the length of treatment. In other words, the physician has a key role in determining both the medical need for, and utilization of, many health care services, including those furnished and billed by other providers and suppliers. Physicians are required to certify to the medical necessity for any service for which they submit bills to the Medicare program. Physicians are involved in attesting to medical necessity when ordering services or supplies that must be billed and provided by an independent supplier or provider. Medicare requires physicians to certify to the medical necessity for many of these items and services through prescriptions, orders, or, in certain specific circumstances, Certificates of Medical Necessity (CMNs). These documentation requirements substantiate that the physician has reviewed the patient’s condition and has determined that services or supplies are medically necessary. Two areas where the documentation of medical…

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