Wiki Case reviews to determine "Medical Necessity" for Inpatient Admission vs Observation/Outpatient status

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gonzalezm27

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I'm being asked to review inpatient admission cases to review "Medical Necessity" to determined whether a patient should of been placed inpatient vs being placed in observation status or having the treatment provided outpatient instead. I've informed management that my CPC and CPMA credential certify that I am knowledgeable in "Medical Necessity" review for the purpose of correct code selection or to provide provider education regarding appropriate documentation guidelines NOT to question a physician's decision or judgment for having placed a patient Inpatient vs outpatient for treatment. I don't feel comfortable making a call regarding a patients admission status, furthermore questioning or second guessing a providers judgement or decision, Am I wrong?
 
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That is appropriate for clinical provider peer review (CPPR), i.e., peer review by a fellow MD/DO, or the utilization review (UR) committee — not left to the judgment of a non-clinical CPC or CPMA.
 
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xXxPARAGONxXx said:
That is appropriate for clinical provider peer review (CPPR), i.e., peer review by a fellow MD/DO, or the utilization review (UR) committee — not left to the judgment of a non-clinical CPC or CPMA.
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Thank you so much for your response makes me feel a bit better. However I'm being forced to do it regardless because the decision was already made by management . This scenario is now forcing me to have to seek employment elsewhere. So unfortunate.
 
gonzalezm27 said:
Thank you so much for your response makes me feel a bit better. However I'm being forced to do it regardless because the decision was already made by management . This scenario is now forcing me to have to seek employment elsewhere. So unfortunate.
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That's unbelievable. Ugh. I take it you're not in a union?
 
I absolutely would not question the medical necessity of provider documentation. I might would ask can you tell me why this is medically necessary but what you are being asked to do goes beyond the scope of an auditor. I have asked before can they clarify in the documentation why the service was medically necessary but if they admit, then they have decided as a health care provider that the admit was medically necessary. If you have to do this, then get all of the ask of you in writing. And make it clear in writing that you are not clinical and feel this is beyond the scope of what you are trained to do.
 
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