Healthcare Fraud -- Lack of Medical Necessity for Medicare and Medicaid Services

Some health care providers bill Medicare and Medicaid for services or procedures that are not medically necessary. They would be liable under the False Claims Act for those false billing practices.


A Florida chiropractor who owned several clinics required doctors whom he hired to order X rays, diagnostic tests and other therapies regardless of the needs of the patients. He also billed for tests never given, such as pelvic X rays, and submitted duplicate claims for the same services. He was sentenced to five years in prison and ordered to pay $1.6 million for defrauding Medicare, the Railroad Retirement Board and private insurers.

A New York radiologist systematically billed Medicaid for thousands of medically unnecessary, duplicative, forged and unreadable sonogram tests. His Medicaid billings went from $8,200 to more than $2.2 million in two years and involved huge kickbacks to more than 50 so-called "salesmen." He was excluded from Medicare and state health care programs for 10 years and sentenced to one to three years in prison.

A chiropractor and his wife, operators of several vascular diagnostic centers in Florida, submitted billings for vascular testing as being ordered by a medical doctor when they were actually ordered by the chiropractor himself. They also practiced deceptive advertising, backdated diagnostic prescriptions, used unauthorized signatures of various medical doctors, altered patient medical records and obstructed a criminal investigation. They were sentenced for conspiracy in defrauding Medicare and private insurance carriers from 1985 through 1990. The chiropractor was sentenced to 51 months imprisonment, his wife to 37 months. In addition, the pair were ordered to make restitution of $637,000.