But, for the most part, that $14.6 billion did not come from taxpayers. Or at least it was not supposed to.
That is because federal health care programs do not cover medical procedures that are not “medically necessary.”[5] That includes elective cosmetic surgery procedures.
Some healthcare providers, however, see procedures that are covered by federal payors and that are similar to non-covered cosmetic procedures, and bill those codes to federal payors, going so far as to create medical records to support the covered procedure. That is when surgeons and their employers get into big trouble. And one Iowa surgeon found himself in that big trouble last week.
DOJ’s Latest False Claims Act Complaint
On May 9, 2023, the U.S. Department of Justice filed a False Claims Act complaint against an Iowa surgeon, alleging that the surgeon, among other things, billed government-funded payors for elective cosmetic surgeries that were not medically necessary, but took steps to mask those surgeries to make them appear to be other, covered procedures.[6] Specifically, the government’s complaint gives examples of giving patients “tummy tucks” following the patients’ “interest in body contouring,” but billing Medicaid for “hernia repairs.”[7]
The Justice Department pointed out in its press release the harsh reality the surgeon is now facing: that if he is found liable under the False Claims Act, the United States will obtain a judgment against him for three times the amount the government...
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