DEBATE: AGREE OR DISAGREE WITH THE STATEMENT:

The False Claims Act (FCA) is meant to protect the Government from being overcharged on goods or services. It is illegal to submit claims for payment to Medicare or Medicaid that are false or fraudulent and each service billed to Medicare or Medicaid counts as a claim, fines can be imposed of up to three times the programs' loss plus additional penalties per claim filed (Office of Inspector General, n.d.).

In the "Second-Guessing" paper the question of varying options on medical necessity and if those claims can be properly made as medical necessity can be based on the physicians medical opinion. The writers explain the "medical necessity is a matter of substantial disagreement as to which reasonable, qualified physicians can and do differ" (Pearlstein et al., 2017). Medical necessity is required to bill Medicare for claims and Medicare states medical necessity is "health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine" (Medicare, n.d.).

In my opinion many FCA claims based on medical necessity cannot be claimed as fraud unless it was clearly against recognized standards of medicine. Unfortunately, cases of fraud still exist where medical doctors are performing procedures without medical necessity such as in the United States v. Javaid Perwaiz case and it is important to have consequences for such false claims. However, the basis that difference in medical opinion can stand as a basis of a fraud claim would likely not be substantiated unless proof of the lack of necessity based on standards of care. Yet, in unsubstantiated claims, the reputation of the provider may be dragged through the mud during the investigative process.

DEBATE: AGREE OR DISAGREE WITH THE STATEMENT?