Physician Provides Definition of Medical Necessity Used to Uphold Fraud Conviction

The conviction of a cardiologist in Ohio for filing false claims as a result of providing services that were not medically necessary was upheld by the United States Court of Appeals for the Fifth Circuit.  In the case of Patel v. United States of America the physician provided the definition of medical necessity during his testimony which was used to determine that some of the service he provided were unnecessary and fraudulent.   He testified as to  the circumstances in which the procedure in question needed to be performed, and the jury determined that 51 of those services did not meet the physician’s own requirements as necessary.  Expert witnesses confirmed that in the cases in which he was convicted services should not have been provided. In addition, his own actions demonstrated knowledge of  providing unnecessary procedures. Finally, the jury’s finding that some procedures alleged to be fraudulently performed were medically necessary while others were not does not invalidate the convictions.  The cardiologist was charged with 91 counts of fraud and convicted of 51 counts.

Medical Necessity

The cardiologists argued that his conviction was based on a vague term “medical necessity” that is open to subjective interpretation of physicians.  His conviction was not based on customary types of health care fraud such as altering bills, alerting medical records, billing for services never provides, or recruiting patients that were not referred. The government maintained that the physician  knew the services he provided were medically unnecessary and that he billed for them anyway, a violation of 18 U.S.C 1347.

During his testimony the cardiologist described a set conditions that would be required for the services in question to be performed.  In each of the 51 cases for which he was  convicted those circumstances were not met.   In addition several experts for the government testified that no cardiologist would have performed the services billed and for which the cardiologist was convicted.

Actions Indicate Knowledge

 Evidence also showed that once the cardiologist was aware that he was being investigated for fraud, he changed the nature of his practice; he performed less of the suspected procedures, he abruptly cancelled some previously scheduled procedures, and he revised medical findings and determinations after a search warrant was executed at his office.  All of these activities demonstrate consciousness of potential guilt.

Testimony that he made derogatory statements about his patients overheard by his staff after the patients left his office was not only admissible, but provided further evidence of his knowledge of his guilt.  The derogatory statements were admissible because the cardiologist testified that he performed an usually high number of procedures, compared to other cardiologist, out of care and concern for his patients.  The testimony of the derogatory statements goes to show that the cardiologist’s motives for providing so many procedures might not always have been one of  compassion.

The conviction of the cardiologist was upheld based on the evidence that he himself provided at trial. Finally, the cardiologist’s argument that the jury’s verdict was inconsistent  as they acquitted him of 40 counts of fraud for providing the same services and should be thrown out was not accurate as the court said that “juries are entitled to render inconsistent verdicts.”