Copyright (c) 1999 Saint Louis University School of Law
Saint Louis University Law Journal
SYMPOSIUM: THE REASONABLE AND NECESSARY CRITERION AND MEDICARE CONTRACTOR REVIEW OF CLAIMS: EFFORTS TO COMBAT FRAUD, WASTE AND ABUSE IN THE MEDICARE PROGRAM
43 St. Louis L.J. 81
GERALDINE NICHOLSON* AND LENA ROBINS**
This article discusses the on-going efforts by the federal government to combat increasing fraud, waste and abuse in the Medicare program through the use of the "reasonable and necessary" criterion set forth in the Medicare statute. The reasonable and necessary criterion is one of the most important tools for ensuring that the Medicare program makes correct payments. As Congress continues to allocate considerable resources to fighting health care fraud and abuse, the reasonable and necessary criterion plays an increasing role in Medicare's overall strategy to do the following: pay the right amount for services rendered, pay legitimate providers for services furnished to eligible beneficiaries, and pay for services that are covered under the Medicare statute and considered reasonable and necessary in the context of the medical needs of the individual beneficiary.
I. Overview of the Law
The Medicare program, a federally funded health insurance program for the elderly and disabled, 1 generally covers a medical service as a benefit if it falls within the statutory definition of that service, 2 unless the service is expressly excluded under the Medicare statute.
Reimbursement for Medicare-covered services, however, may be conditioned on a number of other provisions as well. The principal exclusionary provision precludes payment for specified items and services, such as most "routine" physical examinations, eyeglasses, and cosmetic surgery. 3 In addition, any item or service which the Secretary determines is "not reasonable and necessary for the diagnosis or treatment of an illness or injury" is excluded from coverage, even ...
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