A realtor was unable to show that a Massachusetts hospital knowingly falsely billed Medicare for unused BOTOX units.
A former patient of Lahey Clinic Hospital, Inc. was unable to state a qui tam action against the hospital for knowingly submitting reimbursement claims to Medicare for unused units of the drug botulinum toxin Type A (more commonly known as "BOTOX"), inducing the government to release funds to Lahey far in excess of Medicare billing guidelines, according to the federal district court in Boston, Massachusetts. Relator pled conclusory allegations that Lahey should have treated him with those vials without ever establishing that it could have done so. Also, the court found that the realtor’s claim showed at most that a specific provider miscalculated the total units of BOTOX to be billed (U.S. ex rel. Cohen v. Lahey Clinic Hospital Inc., 1:23-cv-11684-NMG (D. Mass. Sept. 30, 2025)).
The patient suffered from hemifacial spasms, which was treated by Lahey’s with injections of BOTOX on a quarterly basis. He received nine injections in total and received between 16 and 20 units. Government payors reimburse providers for the use of BOTOX therapeutic to treat multiple conditions including, hemifacial spasms. The use of BOTOX for cosmetic purposes is non-covered by Medicare. Medicare reimburses providers for unused portions of the drug post-reconstitution. CMS guidelines clarify that the units billed must correspond with the smallest dose available for purchase from...
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