Healthcare Fraud

Lack of Medical Necessity — What It Means For You and Your Practice

If you’re wondering “what is lack of medical necessity,” it may be helpful to first take a closer look at what medical necessity is. Medicare describes medical necessity as, “Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.” Healthcare companies will only cover health-related services that they feel are medically necessary, and each company may have a different definition. 

For example, a cosmetic nose job procedure would not be covered by insurance unless the medical provider deemed the surgery necessary to recover from an accident, a broken nose, etc. In some cases, medical professionals may use their clinical judgement to suggest a service that may not be covered by insurance; however, it is the medical professional’s duty to follow the patient’s insurance provider’s non-coverage guidelines if they are to bill them directly.   

Medical insurance companies have guidelines in place to protect patients from healthcare fraud, including lack of medical necessity.

What is lack of medical necessity? 

In healthcare fraud, lack of medical necessity is when a diagnosis, treatment, or medical service is given to a patient that is not needed to combat an injury, disease, or its symptoms. Unlawful prescribing –– typically of prescription drugs and medical procedures –– is the most common example of lack of medical necessity. Not only does it defraud Medicare and Medicaid, but it can be harmful to patients financially and physically.

How can you be charged with lack of medical necessity?

When prescribing a medical service, treatment, or drug, the medical provider must document the medical necessity for these services so that the government does not reimburse unnecessary procedures. If a healthcare professional or other individual notices unnecessary medical services being provided, they can file a claim against you under the False Claims Act (FAC). 

The False Claims Act is a type of whistleblower law — a law that rewards those who expose types of fraud that results in a financial loss to the federal government. Most False Claim Act violations occur within the healthcare industry, especially with regard to Medicare and Medicaid. 

If you are charged with lack of medical necessity, the government must prove that you knew the items or services provided were unnecessary. These cases can be difficult to prosecute since each health care professional can make their own decisions using clinical judgment –– what they feel is best for the patient. However, that does not mean you won’t face consequences. 

Lack of medical necessity penalties

False claims act penalties for each unlawful contract, bill, or request, depend on the date of the violation and date of assessment, but can run up to $20,000+ per violation. With a False Claim Act violation, however, there’s more on the line than just financial loss. If you’re charged with lack of medical necessity you could face:

  • Loss of your medical license
  • Loss of DEA registration
  • Exclusion of your practice from Medicare and Medicaid 
  • Restitution on top of FAC violation fines 
  • Potential jail time

The right attorney can help you build your case against healthcare fraud accusations. The healthcare fraud attorneys in Fort Worth at Sellers Law Firm have the trial-tested experience to provide quality healthcare fraud defense. 

Sellers Law Firm provides aggressive healthcare fraud defense

If you are accused of lack of medical necessity or any type of healthcare fraud, contact Sellers Law Firm for aggressive healthcare fraud defense today. Your reputation and career is on the line.

You only get one shot at this. Contact us online or call at (817) 928-4222 today. 

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