Billing for Medically Unnecessary Services

In the world of False Claims Act qui tam cases, the concept of medical necessity is a very big issue.

This is because Medicare requires, as a condition of coverage, that services delivered to a patient be “reasonable and necessary for the diagnosis or treatment of illness or injury.” See 42 U.S.C. § 1395y(A)(1)(a). Healthcare providers who wish to participate in the Medicare program must ensure that their services are provided “economically and only when, and to the extent, medically necessary.” See 42 U.S.C. § 1320c-5(A). In other words, Medicare only pays for services that are “medically necessary.”

As patients, we like to believe that doctors, hospitals and other healthcare providers act in our best interests at all times. When a doctor recommends that we take a certain medication, undergo a certain procedure, or even undergo surgery, we take it at face value that the recommendation is medically necessary.

Unfortunately, this is often not the case. Many times, physicians and hospitals are motivated by financial incentives, i.e., the more procedures they perform, the more money they make. Hospitals, run by large corporations, sometimes place perverse incentives upon doctors to “increase the numbers.” This results in the recommendation of medically unnecessary procedures.

A recent case in Miami illustrates this result. In that case, South Miami Hospital agreed to pay $12 million to the United States to settle False Claims Act allegations that one of its physicians was performing medically unnecessary electrophysiology studies and other procedures.

The whistleblower in the Miami case was not a patient, but rather another physician who knew the procedures were medically unnecessary and had the courage to come forward and report them.

This pattern is familiar. Patients seldom recognize when medically unnecessary procedures are being recommended to them. Many times, the sole voice of reason and honesty is another medical professional, sometimes a doctor, sometimes a nurse, sometimes a lab technician, who has the courage to say, “This isn’t right.”

At Rabin Kammerer Johnson, we have represented many brave whistleblowers who have had the courage to stop the wrongdoing of their peers. Contrary to propaganda often issued by large hospital chains and other special interest groups, these whistleblowers are seldom motivated by the financial incentives of a reward. Instead, they are motivated by the best interests of patients they see being mistreated at their workplace on regular basis.

If you are a healthcare professional and you have seen problems of medical necessity at your workplace, feel free to contact our firm for a free and confidential evaluation of your case and your options.