Unfortunately, some FCA cases involve physicians performing medically unnecessary procedures on patients in order to receive reimbursement from federal health care programs. Medically unnecessary procedures are exactly what they sound like – providers perform medical procedures on patients that do not need them, simply to be paid for the unnecessary procedure. Examples of this practice have included dentists performing unnecessary root canals on pediatric Medicaid patients, and physicians performing complicated dermatological procedures to remove skin cancer on patients that did not in fact have cancer.
It is improper to bill government health care programs for services or treatment that are not medically necessary, and to knowingly do so is a violation of the federal False Claims Act.
Examples of successful cases:
- In March of 2012, Odyssey Health Care, a subsidiary of Gentiva, agreed to pay $25 million to resolve civil liability under the federal False Claims Act arising from its billing of claims in 27 states for continuous home care services that were unnecessary, or not performed in accordance with Medicare requirements.
- In Tennessee, a national supplier of durable medical equipment agreed to pay $41.8 million for medically unnecessary products. Over a period of eight years, the supplier submitted claims to Medicare via an automatic billing mechanism without ever checking the veracity of the claims. The claims were submitted for patients for whom the product was not medically unnecessary. In some instances, the submitted claims were for patients who no longer used the equipment or had already died.
- In New York, New York City agreed to settle a Medicaid fraud case for $70 million for medically unnecessary services. The suit alleged that the city squandered taxpayer money by giving 24-hour home nursing services to individuals at the cost of $150,000 per year, when the same work could have been accomplished for $75,000 a year.
In California, four doctors agreed to settle a claim for unnecessary performance of procedures for $32.5 million. The doctors performed medically unnecessary heart surgeries, defrauding Medicare, Medi-Cal, and TRICARE patients. The settlement stems from a claim in which a Catholic priest had a coronary artery bypass procedure recommended to him that ultimately proved to be medically unnecessary. The subsequent investigation found other individuals that had received medically unnecessary surgical procedures.