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D.C. Circuit Court Clarifies Conclusion Regarding a Laboratory's Determination of Medical Necessity

First few Article Sentences

In the D.C. Circuit Court decision, United States ex rel Groat v. Boston Heart Diagnostics Corp, the court found that because labs (including hospital labs and labs owners by hospital affiliates) certify in CMS Form 1500 that all services are medically necessary, the burden is on the labs, not the ordering physicians, to confirm that the tests are medically necessary. In a decision dated Dec. 11, 2017, the D.C. Circuit Court clarified its conclusion and found that a laboratory cannot and is not required to determine medical necessity, and is allowed to rely on the ordering physician's determination that the laboratory tests are medically necessary.

Cooper, Esq., Richard


McDonald Hopkins LLC

Law, Medical Necessity Fraud

January 1, 2018

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