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According to, “Medically Necessary” is defined as “health-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”
Often, the status of patients at the time of admission or discharge significantly influences the amount and method of reimbursement hospitals receive. Therefore, hospitals have a duty to ensure that admission and discharge policies are updated and reflect current CMS rules.

Whether the patient enters the facility through the emergency department (ED), endoscopy, cardiac cath lab, surgery, or as a direct admission, it's important to know how a determination is made for outpatient or inpatient status and whether medical necessity is a consideration.

At American Healthcare Audit Professionals we have experienced Nurse Auditors and Certified Case Managers with extensive clinical background in providing prompt and professional services in conducting Concurrent reviews in determining whether a patient's status is appropriate.

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