Hospitals must ensure that the services provided in their facilities are medically reasonable and necessary. when a hospital turns a jaundiced eye to these responsibilities, proper use of the False Claims Act has enough teeth to hold these hospitals accountable.

Based on recent successful recoveries, the Justice Department is particularly interested in hospitals that fail to adequately monitor physicians who perform medically unnecessary surgeries. These cases float to the top of the DOJ priority list when there is evidence of patient harm.

Oftentimes, the Justice Department seeks a criminal conviction of the physician. For instance, in August 2013, a federal grand jury indicted a spine surgeon for allegedly fooling Medicare patients into undergoing medically unnecessary spinal surgeries. According to the indictment, the surgeon misled patients by telling them that their medical situations were urgent and that back surgery was needed right away. For cervical spine patients, he would allegedly tell them that there was a risk of paralysis or the head would “fall off” if the patient was in a car accident, because there was almost nothing attaching the head tot he patient’s body.

Through False Claims Act enforcement, the Justice Department recovered some of the Medicare dollars wasted on these medically unnecessary procedures. The United States recovered $4.1 million in a False Claims Act qui tam lawsuit filed against Cincinnati-based West Chester Hospital, the hospital where the surgeon allegedly performed the procedures. The relators in this case were patients who allegedly underwent medically unnecessary surgeries.

More information for whistleblowers is located at the Nolan Auerbach & White website.