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Understanding Medicare's criteria for “reasonable and necessary” is one giant step toward getting paid for concurrent care.

Fam Pract Manag. 1999;6(7):10-11

As a family physician, you've probably treated many hospitalized patients with complicated conditions, sometimes calling in other specialists for assistance. For example, a patient hospitalized with diabetes mellitus and a serious heart condition may need your care as well as concurrent care by a cardiologist. It seems pretty straightforward — unless the patient is covered by Medicare. To increase the likelihood that Medicare will pay for your services in a case like this, you need to understand how Medicare defines and covers concurrent care.

What is it?

According to section 2020E of the Medicare Carriers Manual, a patient receives concurrent care when “services more extensive than consultative services are rendered by more than one physician during a period of time.” Consequently, a consultation with another specialist wouldn't be considered concurrent care; however, the care provided to the patient in the example above would be.

Getting paid for it

Understanding Medicare's definition of concurrent care is still no guarantee that you'll be paid. Medicare also requires that, when more than one physician has an active role in a patient's treatment, the care must be “reasonable and necessary.” To determine whether the concurrent care that you and other physicians provide is reasonable and necessary, Medicare uses the following (admittedly circular) criteria:

  1. The patient's condition must warrant the services of more than one physician on an attending (rather than consultative) basis.

  2. The individual services provided by each physician must be “reasonable and necessary.”

To establish whether the services meet the first criterion, the Medicare carrier will consider the specialty of each physician involved and the patient's diagnosis to determine how they align with Medicare's definition of concurrent care (i.e., that the patient's condition requires diverse, specialized medical or surgical services). Medicare is less likely to view concurrent care as reasonable and necessary if it's provided by physicians of the same specialty or by physicians with a similar knowledge base. For example, if a family physician and a general internist provided care for our hypothetical patient, Medicare might question the claim because the skills and knowledge of a general internist and a family physician overlap and may not be, at least in Medicare's eyes, different enough to necessitate active care from both physicians.

What if the Medicare carrier determines that the patient does indeed require care from more than one physician? This still doesn't ensure payment. The individual services must also meet Medicare's standards for “medical necessity,” just as they would if only one physician were providing the care. For example, if the services you provided to our hypothetical patient exceeded Medicare's standards for frequency or duration, then Medicare might still deny payment for them, just as it would if the patient were not receiving concurrent care.

In addition, the services of one physician must not duplicate those provided by another. For example, if both the family physician and the cardiologist were to make a postoperative courtesy visit to our hypothetical patient, the carrier might consider the visits duplicative.

Finally, because the Medicare carrier must determine whether the patient's condition warrants the services of more than one attending physician, you should anticipate that the carrier will ask for more than the usual documentation for concurrent-care claims.

The hassle factor may be a little greater with concurrent-care claims, but at least Medicare does cover them. Don't let a carrier tell you that Medicare policy automatically precludes payment for a primary care physician's services when another specialist is also caring for the patient for a similar diagnosis. It just isn't so.

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