Medical necessity fraud involves a knowingly false certification by a healthcare provider that a treatment given to a patient is medically necessary. Medical necessity fraud is illegal and, along with things like upcoding and unbundling, is considered part of what is more broadly known as “medical billing fraud.”

Medicare, Medicaid, and Tricare only provide coverage for health-related services that are medically necessary, as stated by law. Medicare defines medically necessary as “health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms that meet accepted standards of medicine.” Under this definition, Medicare, Medicaid and Tricare are only meant to cover treatments, tests or procedures to treat or diagnose a health problem. Medication injections like Botox for face wrinkles, for example, would likely not be deemed medically necessary and therefore would not be covered. Similarly, providing home health care services to a patient who is not actually homebound under Medicare’s regulations would also not be covered.

The structure of Medicare, Medicaid and Tricare, and the related regulations, make this fertile ground for malpractice. Medical necessity fraud always involves a doctor or other health professional selecting treatment or services that allow for more Medicare, Medicaid or Tricare reimbursement than is needed to treat the patient under accepted medical norms, which may pose a danger to patient safety. Common areas of medical necessity fraud include:

  • Opting for surgery when nonsurgical treatment options may be just as effective
  • Intentionally prolonging hospital stays when medical norms would suggest release
  • Prescribing in-home or hospice care that is beyond what is medically needed for that particular patient
  • Unnecessary ambulance or other emergency transport chosen simply to increase the amount of reimbursement from a Medicare or Medicaid provider
  • Ordering excessive patient diagnostic testing or prescribing unnecessary drugs to patients

Because medical necessity fraud is so difficult to detect from a pure auditing perspective, whistleblowers are crucial to detecting and exposing fraudulent providers who are breaking the law. Whistleblowers who work in or interact with fraudulent providers have the knowledge to help stop this type of medical necessity fraud and protect patients from mistreatment. With the help of a lack of medical necessity attorney, whistleblowers may be rewarded financially and receive a percentage of what the government recovers.

Contact a Medical Necessity Fraud Attorney


Medicare, Medicaid and Tricare healthcare providers are subject to the False Claims Act (FCA) because they are considered government contractors by law. The FCA allows the government to recoup funds it has given to contractors based on false claims for payment.

The FCA also allows individuals with knowledge of Medicare fraud, including medical necessity fraud, to file suit on behalf of the government to recoup money that was fraudulently obtained by health care providers despite a lack of medical necessity. Whistleblowers file these actions under seal, making them highly confidential. The FCA also affords these whistleblowers statutory protection from employment retaliation if they work for the healthcare services provider when they file a complaint alleging medical necessity fraud.

Additionally, the whistleblower is entitled to compensation for bringing forth a successful FCA case on behalf of the government. Under the False Claims Act, this amount can be as high as 30% of the total amount recovered depending on the type of information the whistleblower provides.

The amount of the award also depends on the role the government plays in the litigation. Under the FCA, the government has the right to intervene in the case and is provided a period of time to decide whether they will take over the case. If the case is taken over by the government, the whistleblower can obtain between 15% and 25% of the funds recouped by the government depending on their involvement with the government effort and the quality of information they provide. The whistleblower is also entitled to reimbursement of their costs and fees in bringing the action. If the government chooses not to intervene, a whistleblower is entitled to between 25% and 30% of the total recovered plus their costs and fees.


Rewards for whistleblower cases can be significant. In 2017, the government recovered more than $2.4 billion from healthcare providers for fraud. In the medical necessity fraud area, settlements in FCA cases have reached amounts in excess of $100 million. Such cases often begin with whistleblowers coming forward with claims of illegal, provider-wide practices of seeking reimbursement for treatment that is not medically necessary.

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It’s crucial to have an attorney who knows how to prove a medical necessity fraud case. Whistleblowers can face severe personal and professional harm if they step forward without an attorney who knows the law by their side.

Medical necessity fraud cases under the FCA are some of the most sensitive, procedurally difficult, and factually complex lawsuits in the civil justice system. Drafting complaints under the FCA requires close attention to detail, hard work, and knowledge of the elements of a successful medical necessity fraud claim. It is a delicate task that requires serious attorney know-how and experience.

The attorneys at Price Armstrong have experience in successfully representing whistleblowers in FCA cases. If you have information about medical necessity fraud, an attorney at Price Armstrong is available for a confidential, free consultation regarding your options.

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If you have evidence of past or ongoing medical necessity fraud, contact the attorneys at Price Armstrong. We can help you seek justice and protect your rights throughout the process. We represent clients nationwide with offices in Birmingham, AL, Tallahassee, FL and Albany, GA. Complete a form, start a chat or call us today at (205) 208-9588 for a free initial consultation and review of your case. Let us fight for you – call now!