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Federal Appeals Court Holds Medical Judgment Not Valid False Claims Defense
The 10th Circuit Court of Appeals found that a doctor’s certification that a procedure was “reasonable and necessary” is false if the procedure doesn’t meet the government’s definition of what is reasonable and necessary, as determined by the Medicare Program Integrity Manual. Among the requirements is that the procedure is safe and effective; not experimental or investigational; and appropriate, including in duration and frequency. A doctor's subjective judgment as to "reasonable and necessary" was irrelevant.
Read more here: https://www.bna.com/medical-judgment-not-n73014477299/