Are All ‘Medical Necessity’ Determinations Subject to False Claims Act Liability? Opinions May Differ.

Two federal appellate-court decisions handed down in the past few weeks have generated much speculation about whether “medical necessity” determinations underlying Medicare or Medicaid claims can now be considered “objectively false” — despite conflicting medical-expert opinions — and actionable under the False Claims Act (FCA). The most recent opinion was issued on July 9, 2018, in United States ex rel. Polukoff v. St. Mark’s Hospital (“Polukoff”).  Polukoff involved two cardiac surgical procedures reimbursed by Medicare, each of which involved the closing of a hole between the two upper chambers of the heart.  In reversing the District Court below, the Tenth Circuit Court of Appeals in Polukoff, reading the FCA “broadly,” concluded that the procedures, challenged as medically unnecessary, can form the basis for FCA liability.  Similarly, on June 25, 2018, the Sixth Circuit Court of Appeals, in…

Read more detail on Recent Administrative Law posts –

This entry was posted in Administrative law and tagged , , , , , , , , . Bookmark the permalink.

Leave a Reply