US · guidance
CMS Pub. 100-04, ch. 30, § 30.4
Fraud, Abuse, Patently Unnecessary Items and Services
Generally, the protection under the FLP provisions cannot be afforded to a healthcare
provider or supplier if a formal finding of fraud or abuse has been made with regard to a
healthcare provider’s or supplier’s billing practices. In cases where a formal finding of
fraud or abuse is made, an immediate finding of liability for the healthcare provider or
supplier results. Abuse exists when a healthcare provider or supplier furnishes item
and/or service that are inconsistent with accepted sound medical practices, are clearly not
within the concept of reasonable and necessary as defined by law or regulations, and, if
paid for, would result in an unnecessary financial loss to the program. The Medicare
contractor will also make an immediate finding of liability in situations where a
healthcare provider or supplier furnishes items and/or services that are so patently
unnecessary that all healthcare providers or suppliers could reasonably be expected to
know that they are not covered.
History
(Rev.: 4197; Issued: 01-11-19; Effective: 04-15-19; Implementation: 04-15-19)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
459ac4ac14eb32411c98ac99dc2d095c091d44277feb5c1eec238451417e2fa2
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