No Medical Necessity
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As a general rule, Medicare and Medicaid will only pay for services and items that are deemed “medically reasonable and necessary” for the diagnosis or treatment of an illness or injury. National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) identify which tests and procedures require additional medical necessity documentation before they will be approved for reimbursement.
Even if a service is determined to be "reasonable and necessary," however, reimbursement may be limited or denied if the service is provided more frequently than allowed under Medicare coverage policies. When claims for reimbursement are submitted for tests, procedures or services that are deemed "not medically necessary," then the claims are considered to be “false claims” under the False Claims Act. Common types of false claims involving no medical necessity include misrepresenting the diagnosis and symptoms on a patient’s records and billing invoices to obtain payment for unnecessary lab tests, performing inappropriate or unnecessary procedures, or prescribing drugs, durable medical equipment, or treatments that are not a medically necessary. Examples of No Medical NecessityAmbulance Fraud
An ambulance company in Pennsylvania and its owners and operators were indicted for ambulance fraud. The charges include conspiracy to commit health care fraud, making false statements in connection with health care matters, aggravated identity theft, paying kickbacks to patients, and money laundering. Click here to read more.... Ambulance Fraud A local rescue squad employee who went along with her employer's submission of false claims to Medicare for non-emergency ambulance transports was sentenced to 2 years probation and ordered to pay $750,000 in restitution. If she had reported the fraud instead, should could have received a whistleblower reward. Click here to read more.... Ambulance Fraud The owner of a medical transportation company has been indicted on seven counts of health care fraud. The government alleges that he defrauded Medicaid of $406,000 by filing false claims on behalf of his ambulette company. Click here to read more.... Ambulance Fraud Four individuals were charged with allegedly participating in a fraud scheme at Alpha Ambulance Inc., which led to approximately $49.2 million in fraudulent billing for ambulance transportation. According to court documents, the defendants provided beneficiaries ambulance rides that were medically unnecessary. Click here to read more.... Dental Fraud A dentist was sentenced to three years probation and a $1,000 fine after pleading guilty to submitting false claims to Medicaid, including billing for sedative fillings that were not provided or not medically necessary. Click here to read more.... Diagnostic Testing Fraud A physician was sentenced to the statutory maximum of 10 years in prison for billing Medicare for comprehensive exams and a broad array of diagnostic tests that were not medically necessary. Click here to read more.... Durable Medical Equipment (DME) Fraud The owner of durable medical equipment companies has been sentenced to 13 years in prison after a jury convicted her of submitting false claims to Medicare. Click here to read more.... Durable Medical Equipment (DME) Fraud A physician and the owner of a medical supply company pleaded guilty to a conspiracy to defraud Medicare by submitting false claims for power wheelchairs. The physician was paid $300 for each prescription he wrote for power wheelchairs. In most instances the patient did not require or want a wheelchair, and in many instances no power wheelchair was provided. Click here to read more.... Durable Medical Equipment (DME) Fraud The owner of a durable medical equipment (DME) company was sentenced to more than three years in prison for filing false Medicare claims for "ortho kits," which are braces used for various parts of the body. The DME business owner billed Medicare for ortho kits that patients did not need, were not prescribed, and often did not receive. Click here to read more.... Durable Medical Equipment Fraud Four defendants, including a licensed practical nurse, were charged for their roles in fraud schemes involving approximately $2.4 million in false claims for medically unnecessary durable medical equipment. Click here to read more.... Durable Medical Equipment Fraud A pharmacy owner was sentenced to more than eleven years in prison and ordered to pay $15.4 million in restitution for billing Medicare for durable medical equipment (DME) that was not medically necessary. Click here to read more.... Durable Medical Equipment Fraud A durable medical equipment (DME) supplier was sentenced to 30 months in prison for submitting almost $1 million in false claims to Medicare for expensive, high-end power wheelchairs. The defendant admitted that he supplied power wheelchairs to Medicare beneficiaries who were illegally solicited by patient recruiters or “marketers” for medical equipment they did not want or need. Click here to read more.... False Physician Certification Statements Orthofix, Inc. agreed to pay more than $42 million to settle allegations that it violated the False Claims Act by submitting false certificates of medical necessity to Medicare and paying kickbacks to surgeons. The whistleblower who brought the qui tam lawsuit received a $9 million reward. Click here to read more.... Home Health Care Fraud Two patient recruiters for a home health care company pleaded guilty to soliciting kickbacks and bribes from their employer in return for recruiting patients. Their employer then billed Medicare for services that were not medically necessary and, in some cases, not provided to the patients. They each face up to five years in prison and a $250,000 fine or twice the gain or loss involved. Click here to read more.... Home Health Care Fraud Seven individuals were indicted and arrested on charges of using their home health care agencies to defraud Medicare of $22 million in false claims. The defendants are accused of billing Medicare for physical therapy and skilled nursing services that were not medically necessary and, in some cases, never provided. Click here to read more.... Home Health Care Fraud The owners and operators of two home health agencies pleaded guilty to submitting Medicare claims for home health care and therapy services that were not medically necessary. Click here to read more.... Home Health Care Fraud The owner of a home health care business was sentenced to ten years in prison for billing Medicare for services that were not medically necessary, including uncomfortable nerve conduction tests. Click here to read more.... Home Health Care Fraud Three defendants – a medical doctor and two registered nurses – were charged with participating in a fraud scheme that resulted in approximately $100 million in fraudulent billing for home health care services. According to court documents, Dr. Joseph Megwa signed approximately 33,000 prescriptions for more than 2,000 Medicare beneficiaries whose primary care physicians never certified home healthcare services for them. Click here to read more.... Inpatient Hospital Admission Fraud Wyoming Medical Center agreed to pay $2.7 million to settle claims that it submitted false or fraudulent claims to Medicare for unnecessary inpatient admissions. Click here to read more.... Inpatient Hospital Admission Fraud Wyoming Medical Center agreed to pay $2.7 million to settle claims that it submitted false or fraudulent claims to Medicare by prolonging inpatient hospital admissions without medical necessity in order to qualify patients for Medicare-covered, long-term care at a skilled nursing facility. Click here to read more.... Interventional Cardiology Fraud A medical center and a physician practice group agreed to pay $4.4 million to settle allegations that they submitted false claims to Medicare for cardiac procedures that were not medically necessary. The questioned procedures included angioplasty and stent placements in patients who, the government contended, had heart disease but whose blood vessels were not sufficiently occluded to require the particular procedures at issue. The whistleblower who brought the lawsuit will receive a $660,859 reward under the qui tam provisions of the False Claims Act. Click here to read more.... Interventional Cardiology Fraud A physician who practiced interventional cardiology for more than 25 years was sentenced to ten years in prison for performing unnecessary coronary procedures such as deploying angioplasty balloons and stents. Click here to read more.... Medical Device Fraud A territory manager for a medical device company was sentenced to one year of probation and forfeiture of $10,000 for altering patient medical records to make it appear that patients qualified for Medicare reimbursement for his employer's products when they did not qualify. Click here to read more.... Mental Health Fraud A registered nurse and an intake specialist at a community mental health center have pleaded guilty to conspiracy to commit health care fraud for helping their employer bill Medicare and Medicaid for mental health treatment that was unnecessary. Click here to read more.... Neurological Testing Fraud A physician was sentenced to five years in prison for billing Medicare for unnecessary neurological tests. The evidence showed that patients were not referred by their primary care physicians or for any other legitimate purpose. Rather, they were recruited with prescriptions for controlled substances, cash payments, and fast food. Click here to read more.... Nursing Home Fraud A former nursing home employee will receive a $405,000 whistleblower reward for helping the government uncover false claims submitted to Medicare and Medicaid for physical, occupational, and speech therapy services that were not medically necessary. Click here to read more.... Partial Hospitalization Program (PHP) Fraud The owners of assisted living facilities and an affiliated psychologist received stiff prison sentences ranging from 28 months to 63 months for defrauding Medicare. The defendants paid kickbacks to other assisted living facilities for referrals of Medicare patients for Partial Hospitalization Program (PHP) treatment that was unnecessary and, in many instances, not provided. Click here to read more.... Partial Hospitalization Program (PHP) Fraud A former clinical director at a mental-health clinic was sentenced to more than eight years in prison for helping his employer submit more than $50 million in false and fraudulent claims to Medicare for individuals who were not eligible to participate in a Partial Hospitalization Program (PHP). Click here to read more.... Pharmacy Fraud A pharmacist was sentenced to 17 years in prison for health care fraud. The pharmacist, who ownede and operated 26 pharmacies, was accused of billing Medicare and Medicaid more than $57 million drugs that were not medically necessary or not actually dispensed. He was also accused of paying kickbacks to physicians in exchange for writing prescriptions for expensive medications without regard to medical necessity. Click here to read more…. Physical Therapy Fraud Therapists who once worked at a Virginia nursing home will receive a whistleblower reward of $122,500 for helping the government recover $700,000 in a Medicare fraud case against their former employer. Their qui tam lawsuit alleged that services billed to Medicare were not necessary for treatment of the patients’ conditions and, in some instances, treatment was provided or extended solely for the purpose of billing Medicare. Click here to read more.... Physical Therapy Fraud A physician and six others were charged with conspiring to defraud the Medicare and Medicaid programs of more than $13 million by submitting fraudulent claims for physical therapy and other medical services that were were medically unnecessary. Click here to read more.... Physical Therapy Fraud Nine defendants were charged with participating in a fraud scheme which led to approximately $13.8 million in fraudulent billing for physical therapy and related services. According to court documents, the defendants paid cash kickbacks to Medicare beneficiaries in exchange for physical therapy that was not medically necessary. Click here to read more.... Prescription Fraud A physician is facing up to 60 years in prison after a jury convicted him of healthcare fraud for writing unnecessary prescriptions for medical equipment and nutritional supplies that were never provided to patients. Click here to read more.... Prescription Fraud A physician faces up to five years in prison and a $250,000 fine after pleading guilty to writing prescriptions for narcotic pain medications that were not medically necessary. The government alleges that the physician continued to prescribe unnecessary pain medications to patients so they would return to his office every month for more prescriptions and diagnostic testing that was also not medically necessary. Click here to read more.... Psychotherapy Fraud A dermatologist and a psychologist were charged with Medicare fraud for billing millions of dollars in false claims for medically unnecessary laser treatments and psychotherapy services. Click here to read more.... Psychotherapy Fraud A psychologist was charged in a fraud scheme involving, according to court documents, millions of dollars in false claims for medically unnecessary psychotherapy services. Click here to read more.... |
John Howley, Esq.
The Howley Law Firm P.C. 350 Fifth Avenue, 59th Floor New York, New York 10118 (212) 601-2728 |