Unnecessary medical care provided to patients — often referred to as a lack of medical necessity — not only defrauds Medicare and Medicaid, it also can seriously harm patients.

Medical necessity is an important requirement for Medicare claims to protect patients and prevent Medicare fraud. The law prohibits Medicare from paying for healthcare services that are not medically reasonable and necessary.

Whistleblowers recently have won important appellate court decisions on the issue of whether healthcare providers’ false representations that treatment is medically necessary can be considered Medicare fraud. A physician’s determination of medical necessity can be false if they do not believe it, know of facts that preclude it or recklessly disregard whether it is true.

Healthcare professionals and others who are aware of unnecessary medical care being provided can report the fraud and help stop it by filing a whistleblower (“qui tam”) lawsuit under the False Claims Act. The law provides job protection and rewards for whistleblowers.

Whistleblowers have been responsible for stopping many instances of unnecessary medical care. Whistleblower cases have alleged a lack of medical necessity in the treatment of Medicare patients by many different healthcare providers, including hospitals, skilled nursing facilities and hospice programs.

One of the most high-profile cases involved hundreds of hospitals that implanted electronic heart devices allegedly before a waiting period required by Medicare to see if the heart could recover from a heart attack or bypass surgery on its own.

More than 500 hospitals in 43 states paid over $280 million to settle the whistleblower case. Two of the lead government prosecutors in the case from the US Attorney’s Office in Miami and from the US Department of Justice have since joined Phillips & Cohen to represent whistleblowers.

If you are aware of unnecessary medical care of Medicare patients by a particular healthcare provider and would like to find out what your options are to stop it, contact us for a free and confidential consultation.

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