Lack of Medical Necessity

Federal healthcare programs such as Medicare and Medicaid only cover services or products that are medically necessary. Medically necessary services or supplies are those that are proper and needed for the diagnosis or treatment of a medical condition, meet the standards of good medical practice, and are not mainly for the convenience of the patient or doctor. Doctors are typically required to certify that their services rendered were medically necessary prior to being reimbursed by Medicare or Medicaid.

Unscrupulous doctors often provide medically unnecessary services, including invasive surgeries or procedures that put patients at risk. Cases successfully prosecuted under the False Claims Act have included doctors inserting thousands of coronary artery stents in patients with only mild arterial blockage and doctors performing unnecessary spinal surgeries, some of which led to permanent patient disability.

If you have experienced or witnessed doctors performing procedures that appear to lack medical necessity, you may have a whistleblower claim.