Florida Unreasonable Cost of Goods/Services Lawyer
Federal healthcare programs like Medicare and Medicaid only reimburse healthcare providers for services that are deemed reasonable and necessary for the diagnosis or treatment of a patient. To this end, healthcare providers are required to certify, whenever they submit a claim for payment, that the items or services for which reimbursement is being sought were both medically reasonable and necessary. Unfortunately, some healthcare providers certify treatment as being both reasonable and necessary when it is neither, which falls squarely within the confines of healthcare fraud. Unscrupulous healthcare providers who engage in these kinds of dishonest billing practices can be held accountable for their actions, so if you are or were employed by a healthcare provider who uses unethical billing practices, you should reach out to an experienced Florida unreasonable cost of goods/services lawyer who can help you through the claim filing process.
What Qualifies as Reasonable and Medically Necessary?
The Centers for Medicare & Medicaid Services (CMS) defines medically necessary services as those services that:
- Are proper and necessary for the diagnosis or treatment of a patient’s medical condition;
- Are provided for the diagnosis, direct care, and treatment of a patient’s medical condition; and
- Meet the standards of good medical practice in the local area and are not performed merely for the convenience of a patient or doctor.
In contrast, experimental, investigative, or unproven methods and services are typically excluded from coverage under these federal programs.
Examples of Unreasonable and Unnecessary Medical Care
For every service for which they charge, healthcare professionals must indicate the specific sign, symptom, or complaint that makes a particular service both reasonable and necessary. There are, however, certain services that are never deemed to fall under this category, including:
- Hospital furnished services that could have been provided in a lower cost setting, like a beneficiary’s residence or a nursing home;
- Hospital services that exceed Medicare’s length-of-stay limitations;
- Excessive therapy or diagnostic procedures;
- Unrelated examinations, screening tests, and therapies for conditions for which a beneficiary has no documented symptoms;
- Unnecessary services based on a patient’s diagnosis, such as acupuncture or meditation; and
- Services or items administered to a patient for the purposes of causing his or her death.
Ambulance transport for patients that are fully mobile or not at risk could also qualify as unnecessary, as can this use of invasive or expensive procedures before attempting to use other drugs or physical therapy. Unfortunately, some healthcare providers perform and charge for these kinds of unnecessary procedures at an alarming rate. It is, however, possible to hold these individuals and entities accountable for their actions under the False Claims Act, so if you are or were employed by a healthcare provider and have information regarding false billing practices, or evidence of the use of other deceptive practices, please reach out to our office today.
Call Today for Help with Your Case
To speak with an experienced Florida unreasonable cost of good/services lawyer about filing a claim against your employer, please call Rabin Kammerer Johnson at 561-659-7878 today.