Every day, doctors and medical facilities across the country submit claims to insurance companies. When it comes to the type of services that are billable, Medicare and other federally funded programs have strict requirements. In many cases, they will deem a service either medically necessary or unnecessarily. When doctors submit claims for services, medications, and equipment that is not medically necessary, it can cause many problems.
It is essential for doctors and medical billers to understand what are medically unnecessary services. Knowing ahead of time what can and cannot be billed for can safeguard your facility against the negative legal implications.
Necessary vs. Unnecessary Medical Treatment
To qualify for coverage under Medicare, Medicaid, and other government-funded programs, the services, medications, and supplies must be deemed medically necessary. Services will generally fall under this category if they are needed to diagnose or treat an illness, medical condition, injury, or any resulting symptoms. The treatment must meet the acceptable standards of medicine.
Examples of Medically Unnecessary Services
Although some services are considered medically necessary, pushing the acceptable billing limit can deem them unnecessary and unbillable. Some examples of medically unnecessary services include:
- Physical therapy that goes beyond the limits established by Medicare
- Expensive medical equipment prescribed before all other treatment options have been exhausted
- Inpatient treatment that is beyond the length of stay limits approved by Medicare
- Prescription medications to treat conditions when the entire service is considered unnecessary (cosmetic surgery is an example of this)
- Hospital services when other cost-efficient locations are available
Ramifications of Billing for Medically Unnecessary Services
When facilities bill for unnecessary services, they can face an array of consequences. Most doctors and providers will be stripped of their licenses to practice. This can be either temporary or permanent, depending on the charges. If convicted, practitioners face lengthy prison sentences and stacking fines. Many medical professionals not only have their careers wholly disrupted, but their reputations and personal lives are often diminished as well. When professionals are falsely accused of billing fraud or committing False Claims Act violations, it is crucial that they retain the legal guidance of a reputable healthcare fraud defense attorney as soon as possible.
Effective Legal Defense is in Reach
There are many instances where vendors, surgeons, and other medical professionals and providers are accused of engaging in fraudulent actions. Being convicted can result in several years of imprisonment and thousands of dollars in fines. When individuals are accused of engaging in illegal activities, it is crucial that you contact an aggressive defense attorney as soon as possible.
Healthcare Fraud Group has decades of experience fighting to protect the rights of those accused of white-collar crimes throughout the entire country. Our team provides aggressive and competent legal representation to help those accused prove their innocence. Contact our law firm today at (888) 402-4054 to protect your legal rights.