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Health care fraud when services are not medically necessary

On Behalf of | Feb 10, 2020 | healthcare fraud | 0 comments

Under the False Claims Act, prosecutors may charge health care professionals with Medicare fraud for submitting a claim for services that a patient does not actually need. Even without the intention to defraud the government, if a medical professional knowingly or recklessly submitted a claim containing false information, he or she may face allegations of fraud.

In one recent case, law enforcement officials charged a 57-year-old Texas resident and business owner with health care fraud.  As reported by East Texas Matters, prosecutors charged him with fraud for submitting claims when patients did not have a medical need for services.

Pleading guilty for fraud

The proprietor owned an ambulance company. Alleging that he billed Medicare and Medicaid for services not considered “medically necessary,” prosecutors filed charges of fraud for transporting patients between dialysis, hospitals and specialized nursing centers.

The accused business owner pleaded guilty. His sentence requires him not to seek employment within the health care industry during his three-year period of supervised release.

Medical necessity defined

Generally, a “necessity” is a medical procedure or service a patient requires for treating or diagnosing an illness or disease. Each insurance provider may, however, have its own particular criteria to meet. Federally funded programs often follow different guidelines than insurance companies to determine a patient’s necessity.

Medicare and Medicaid may cover the cost of an ambulance to receive nonemergency services when a patient has no other means of transportation or is bedridden. The patient’s condition must also present a need for an ambulance to transport the individual to a doctor’s appointment, such as for dialysis or intravenous medication.

Defense against fraud allegations

Maintaining meticulous records of patients and their treatments may counter allegations of health care fraud. While some defendants choose to enter into a plea bargain, the penalties of a conviction can still include incarceration and restitution as well as supervised release. When fighting fraud allegations through a jury trial, a defense tries to show that the prosecutor does not have enough proof to convict a health care professional of the charges.

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