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Billing Without Medical Necessity

For medical services, prescription medications, or health care supplies or equipment to be eligible for Medicare or other federal program reimbursement, they must qualify as “medically necessary”. Services are considered medically necessary when they are, “needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.” The definition of proscribed practiced in the context of the medical-necessity requirement is broader than it may initially seem.

The following services will all generally be considered “medically unnecessary” and are not eligible for federal benefit program reimbursement:

  • Physical therapy sessions that go beyond the Medicare usage limit.
  • Expensive medical equipment that is prescribed before conservative treatments have been exhausted.
  • Inpatient treatment that lasts beyond the Medicare-approved length of stay.
  • Prescription medications to treatment conditions where the entire treatment type is considered medically-unnecessary - such as cosmetic surgery.
  • Hospital services where lower cost facilities was a preferred option.

If your health care firm is being targeted in a federal investigation for allegedly billing for medically-unnecessary services or supplies, Khouri Law Firm defense attorneys can assess your policies, procedures, and reimbursement billing to determine the best course of action.