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When is ordering a lab test a violation of federal law?

Ordering a test for a patient seems like an innocuous and potentially necessary step towards quality medical care, but the government does not always see it this way. The federal government is cracking down on physician practices and hospitals who overutilize testing. They are taking a close look at those who used pandemic assistance programs, checking to see if any of the physicians’ groups used these funds inappropriately. If they find anything concerning, they are investigating and aggressively pursuing criminal charges.

In a recent example, the government went after 21 individuals from nine different federal districts claiming they stole from federally-funded pandemic assistance programs. The feds state the individuals, part of various physicians’ groups, illegally overbilled patients for medically unnecessary services.

The government was able to gather enough evidence to support these allegations. They focused on one specific group, which chose to settle the claim. As a result, the government is holding six physicians’ groups with locations in Texas and Florida that were allegedly part of the scheme liable for the violations. This means the government requires all involved to cover a settlement amount of $24.5 million.

Three important lessons from the case

Physician groups throughout the country can learn three important lessons from this case to avoid the same mistake:

  • Make sure testing is medically necessary. Review testing procedures to make sure physicians are ordering the right test when supported by medical necessity.
  • Keep accurate records. Have medical records available that support the reason for the test.
  • Conduct internal audits. Rules and regulations change. Conduct regular internal audits to make sure practices are in line with applicable regulations. This will give your group an opportunity to adjust before practice rise to the level of a violation.

Attorney John Rivas is responsible for this communication.