Enacted in 1965, Medicare primarily covers individuals aged 65 and over. It is regulated by the Centers for Medicare and Medicaid Services (the “CMS”). While most people are somewhat familiar with Medicare, many do not understand that the services covered by Medicare are governed by a single standard.
The general rule is that Medicare pays for items that are reasonable and necessary to diagnose or treat an injury or illness. A service must meet this standard in order for it to be covered by Medicare. As a result, each Medicare analysis begins by analyzing the health care service provided, as opposed to the patient’s problem or diagnosis. While the rule sounds simple enough, there are questions that come into play when applying it.
The first question that comes up in an analysis of Medicare’s basic rule is what qualifies as reasonable and necessary. While statute does not expressly outline how to factor cost in this first question, they are definitely a part of the analysis. For example, it is likely that Medicare would not cover the use of an overly expensive test. Another important factor is the standard of care. For instance, if it has been shown that a particular form of treatment is widely accepted as proper treatment for an illness, it is more likely that that form of treatment would be considered as “reasonable and necessary.”
The next part of the rule is that the item must be used to diagnose or treat an injury or illness. What this means is that there needs to be an existing complaint from the patient. As a result, Medicare does not cover preventative care.
While this Medicare standard seems simple enough, it is the key for any Medicare analysis. Each case has a different set of facts, but no matter the circumstances, it must meet this simple standard in order for an item or service to be covered by Medicare.
For more information, please contact Vik Chaudhry at (858) 519-7333 or vik@thevclawgroup.com.