Robert Salcido Talks Medical Necessity and False Claims with “Report on Medicare Compliance”

Akin Gump partner Robert Salcido, whose practice focuses on False Claims Act defense, was quoted by Report on Medicare Compliance in its article “MD Going to Prison in Stent Case; Heat Is on Medical Necessity” regarding increasing challenges to the medical necessity of services such as cardiac procedures.  The article cites a recent case in which a physician believed a procedure to be medically necessary, but, in order to ensure coverage, lied about diagnostic test results.

Salcido said that hospitals that employ physicians bear the responsibility for their actions, including orders and decision-making, noting, “At that point, the physicians’ potential false claims become the hospitals’ false claims.”

However, when physicians have hospital privileges and order and perform services at hospitals but are not employed by them, the medical institution has a different accountability under the False Claims Act. Salcido added, “The hospital can only become responsible for the physician’s conduct if it knows the physician is submitting false claims or acts with reckless disregard or deliberate ignorance with respect to the submission of false claims. He also noted that, by and large, the case law supports the premise that “hospitals can reasonably rely on physicians following Medicare rules and regulations unless or until some red flag appears that indicates [otherwise].”