Alyson D. Stover; Client-Centered Advocacy: Every Occupational Therapy Practitioner’s Responsibility to Understand Medical Necessity. Am J Occup Ther 2016;70(5):7005090010. https://doi.org/10.5014/ajot.2016.705003
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© 2019 American Occupational Therapy Association
Occupational therapy practitioners must advocate for clients in multiple ways. The Occupational Therapy Practice Framework: Domain and Process as well as the Occupational Therapy Code of Ethics lend support to advocacy. Recognizing one’s responsibility to provide advocacy for clients is different from knowing how to provide that advocacy. One aspect of health care affected by the Patient Protection and Affordable Care Act (ACA) is the definition and implementation of medical necessity. This article outlines some major concepts around medical necessity, particularly in relation to the passage of the ACA, and outlines guidance on how to advocate effectively to meet both individual and community needs.
As used in this chapter: (1) Disability. The term “disability” means, with respect to an individual (A) a physical or mental impairment that substantially limits one or more major life activities of such individual; (B) a record of such impairment; or (C) being regarded as having such an impairment (as described in paragraph (3)). (42 U.S.C. 126, §12102[1])
health care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms, including habilitation, and that meet accepted standards of medicine. (Center for Consumer Information and Insurance Oversight, n.d ., p. 3)
A service, item, procedure or level of care that is necessary for the proper treatment or management of an illness, injury or disability is one that:Will, or is reasonably expected to, prevent the onset of an illness, condition, injury or disability.Will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability.Will assist the recipient to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the recipient and those functional capacities that are appropriate of recipients of the same age. (§1101.21a)
A service, item, procedure or level of care that is necessary for the proper treatment or management of an illness, injury or disability is one that:
Will, or is reasonably expected to, prevent the onset of an illness, condition, injury or disability.
Will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability.
Will assist the recipient to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the recipient and those functional capacities that are appropriate of recipients of the same age. (§1101.21a)
Medically necessary health care services or products are those that a prudent health care practitioner would provide to a client who is experiencing an exacerbation or event that reflects an interaction between features of his or her body and/or psychological wellness and features of the society in which he or she lives; that limits one or more major life activities; and that affects daily life and major life activities, in a manner that is (1) in accordance with generally accepted standards of . . . practice and (2) clinically appropriate in terms of type, frequency, extent, site, and duration.
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