Government health care programs, such as Medicare, Medicaid, and TRICARE, will not make payments to health care providers for procedures or treatments that are not “medically necessary.” As a condition to payment for services, health care providers must certify that the services for which they seek payment were necessary and can be supported by medical evidence.
Some health care providers may intentionally provide medically unnecessary treatments or procedures to patients as a means of increasing their reimbursement from the government. This type of fraud is in violation of the False Claims Act and can serve as the basis for a qui tam lawsuit under the act.
Recent Real World Examples of Medically Unnecessary Services False Claims Act Cases:
- 2012: NextCare Inc., an urgent care provider, paid $10 million to resolve allegations that the company submitted false claims to federal and state health care programs by fraudulently billing for medically unnecessary allergy tests, H1N1 virus tests, and respiratory panel tests. The initial whistleblower, represented by the Rabon Law Firm, shared in an award of over $1.6 million as a result of the settlement.
- 2010: FORBRA Holdings LLC, a national dental management company, paid $24 million to settle claims that it caused false claims to be submitted to Medicaid by billing for medically unnecessary services provided to indigent children. The medically unnecessary services that were allegedly provided to children and later billed to Medicaid included pulpotomies (“baby root canals”), anesthesia such as nitrous oxide, and extracting teeth, among others. The three whistleblowers who filed qui tam lawsuits received over $2.4 million.