Federal Government Auditing the Medical Necessity of the Service Provided to Medicare Beneficiaries

The federal government in part relies on private contractors, known as recovery audit contractors (RACs), to detect fraudulent activity targeting the Medicare systems. Recently, the federal government, through its agency the Center for Medicare & Medicaid Services, decided to expand one RAC’s auditing powers to include medical necessity reviews. These intensive audits are designed to determine if specific procedures in a Medicare paid claim were medically necessary for a patient’s health. This particular RAC, CGI Technologies and Solutions Inc., reviews Medicare claim in Minnesota, Wisconsin, Michigan, Indiana, Ohio, Kentucky, and Illinois. Lack of medical necessity for inpatient and observation stays is recognized as an area fraught with overpayments.

For more information about qui tam law and Medicare fraud, contact Nolan and Auerbach, PA.