Healthcare fraud is a widespread problem and is one of the most common types of fraud featured in claims under the False Claims Act. Through the FCA, whistleblowers have helped the government recover billions of dollars from pharmaceutical companies, hospitals, doctors, and pharmacies. Medicaid faces major risks of fraud. Medicaid fraud occurs when health care providers intentionally make misrepresentations or deceive the government to gain benefits to which the providers are not entitled. Some providers also engage in abusive practices that are fiscally unsound and that cause the Medicaid program to suffer unnecessary costs. In this type of situation, a provider might ask for reimbursement for medical services that were not medically necessary.
When medical providers are caught engaging in fraud and abuse, they can face civil, administrative, and criminal penalties that include fines, potential prison sentences, and being excluded from participating in Medicaid and Medicare. Understanding the different types of health care fraud and abuse can help workers to identify illegal activities and report them to the proper authorities. The attorneys at Swartz Swidler are prepared to assess your potential claim and advise you about your legal options.
Medical identity theft
In this type of health care fraud, a patient’s medical information is used to obtain funds, services, or health care goods. Medical identity theft occurs when a provider misuses a patient’s medical identity information to bill private or public payors for fraudulent medical services or goods. It can also include stealing the identifiers of physicians to refer patients for unneeded medical services, fraudulently fill prescriptions, or bill for services that were not provided.
Kickback schemes are another type of illegal activity that some members of the health care industry engage in. In these schemes, a health care provider might solicit, offer, pay, or receive valuable goods or cash in exchange for referring patients for care or services to another doctor or facility. When the referrals involve federal health care program beneficiaries, kickbacks are illegal. This can lead to increased costs, overutilization, unfair competition, and corruption of the decision-making process.
In general, medical facilities and doctors are prohibited from receiving or offering any type of remuneration from or to pharmaceutical companies, doctors, health care facilities, or medical device companies in exchange for referring patients, prescribing specific medications, prescribing certain medical devices, or making decisions that could be influenced by the remuneration instead of the patient’s best interests.
Billing for medically unnecessary services
Medicare and Medicaid are only supposed to reimburse providers for expenses or procedures that are medically necessary. Your doctor cannot recommend procedures, tests, or other medical services that are not related to your treatment and are unnecessary for your medical condition. States are allowed to limit services based on medical necessity. Providers are required to ensure that their services are medically necessary before they authorize them. Intentionally billing services that are not medically necessary can result in serious sanctions.
Billing for items and services that were not delivered
It is illegal for medical providers to bill for items and services that were not delivered to patients. Even if a provider delivered different services or items, it is still unlawful. For example, if a provider bills Medicaid for a covered service because the provided service is not covered by the program, it is illegal. It is similarly fraudulent for a provider to bill Medicaid or Medicare for services that were never provided. Providers that do this might create fraudulent records to justify their billing practices. For example, a doctor might document that a patient was seen on a specific date when the patient was not seen. Medical providers might also bill for tests and exams that simply did not happen.
Upcoding is one of the most common ways that providers defraud the government. In upcoding, providers bill for services that were not provided or bill for a more expensive service than the one that was provided. Upcoding can cost the government millions of dollars in each fraud case. You can detect upcoding by closely reviewing medical bills. If you see anything suspicious that did not happen during your visit, your health care provider might be engaging in upcoding. Another example of upcoding might occur when your doctor bills for a complex visit instead of a routine office visit. Upcoding can also be engaged in by medical device companies. For example, a company might bill for a motorized scooter when the patient received a manual wheelchair. If you detect upcoding, you should talk to an attorney to learn about your options.
Unbundling of services involves using multiple codes to bill for several procedures that should be billed under one comprehensive code. In this form of health care fraud, the provider bills the services separately to receive higher reimbursement than what it would receive under the comprehensive code. An example of unbundling might occur when a lab bills each test in a panel separately instead of billing for the panel itself.
Having office staff and nurses perform exams
Medicaid and Medicare billing rules require doctors to perform certain types of procedures. Despite the rules, some doctors have their office staff or nurses perform certain types of routine procedures and then bill for the doctor’s time instead. This is illegal and also could place patients in danger.
Get help from the employment lawyers at Swartz Swidler
Health care fraud causes billions of dollars of losses each year. Without the help of whistleblowers, many fraudulent schemes against the government would not be detected. Whistleblowers help to save taxpayers money by exposing fraud. If their whistleblower cases are successful, they might receive a reward from the government that may range from 10% to 30% of the total amount recovered. If you are aware of health care fraud at your job or by your doctor, you should schedule a free, confidential consultation with the attorneys at Swartz Swidler by calling us at (856) 685-7420.