#7402 Ethical Dilemmas Associated With Medical Necessity Determinations and Dimensions of Rehabilitation Outcomes RECORDED WE

Course overview

The idea of providing health care treatments and insurance coverage according to medical necessity determinations seems eminently reasonable. Its obvious ethical thrust is to discourage unnecessary, wasteful or fraudulent practices. As practically implemented, however, medical necessity regulations and determinations have proven remarkably controversial and have particularly vexed rehabilitation providers. Medical necessity determinations incur problems as to who should ultimately make them: payors, health providers or the courts. Obviously, whoever controls the definition of medical necessity controls the flow of health care dollars. While ethical theory can offer important insights about our moral obligations, it remains unable to reliably translate its theoretical principles and rules bearing on harms, benefits and justice into informing medical necessity determinations. Thus, resolving disputes over medical necessity have taken a procedural approach that looks to the interpretation of contractual language in insurance policies, often at the bench of an administrative law judge.