When Unnecessary Medical Treatments Metastasize into Healthcare Fraud

The bedrock rule of government healthcare reimbursements is that providers will only receive payment for medical care that is both “reasonable” and “necessary.” It is then up to the sound judgment of providers to define what is truly medically necessary. However, as healthcare spending has skyrocketed in recent years, academics, patient safety groups, and government agencies have increasingly scrutinized the medical necessity of various medical treatments. In fact, a recent paper in JAMA sounded alarms about the mounting costs for medically unnecessary treatments, when it estimated “waste” in the United States healthcare system at more than $900 billion a year, of which $300 billion flowed from Medicare and Medicaid.

Undoubtedly, at some point, medically unnecessary treatments leap across the Rubicon from being simply healthcare “waste” to being outright fraud. In most medical specialties, this demarcation between waste and fraud is blurry, at best. However, this line might be coming into focus, in part, because of the efforts of Choosing Wisely, an initiative of the ABIM foundation that “aims to promote conversations between physicians and patients by helping patients choose care that is: supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.”

About a year ago, Choosing Wisely made news when they had nine specialty societies release lists of five things physicians and patients should question. Basically, they came up with lists of things that healthcare providers shouldn’t do when practicing medicine. While they identified such “over-treatments” as “waste,” many of these identified treatments have been outright rejected by the relevant medical communities. In other words, the chorus of medical specialists viewed these particular treatments as “medically unnecessary.”

Undoubtedly, there are health systems and physicians who continue billing government healthcare programs for such unnecessary treatments. Oftentimes, they choose poorly because their desire for monetary gains outweighs their medical judgment. For such healthcare providers, a False Claims Act qui tam lawsuit might be the only effective prescription for fraud.

More information for whistleblowers is located at the Nolan Auerbach website.