The U.S. health care system has become increasingly complex. Health care providers are required to comply with federal and state regulations for billing as well as with private insurance contracts. For this reason, many providers rely on professionals to help them to navigate through this complex system. In some cases, health care organizations will engage in criminal billing fraud by using patient information to bill insurance companies and the government for procedures that were not performed. While this is the traditional way that health care fraud is committed, Some billing practices that are fraudulent are not intended to enrich the doctors. For example, billing a covered service to pay for uncovered services or waiving copays are both illegal even if the provider wanted to help a poor patient.
The experienced qui tam attorneys at Swartz Swidler represent whistleblowers who have non-public knowledge of their employers’ large-scale fraudulent billing schemes against the state and the federal government. We can help you to understand health care fraud so that you can identify if it is occurring at your job. We can also advise you about your legal options.
Federal health care fraud laws
Health care fraud is illegal under the federal False Claims Act. Under this law, it is illegal for health care providers to create false records or submit false claims for billing to the federal government or to any state government. The False Claims Act allows people who have inside knowledge about their employers’ fraudulent billing schemes to file lawsuits on the government’s behalf against their employers. These lawsuits, known as qui tam lawsuits, might allow the plaintiffs or relators to recover rewards of 10% to 30% of the total amount of money that the government can recover through their successful qui tam actions.
Health care providers can also face criminal health care fraud charges under 18 U.S.C. § 1347. Under this statute, providers can be criminally indicted and face felony charges that could result in incarceration, restitution, fines, and the loss of their medical licenses. To be convicted of criminal health care fraud, a provider must knowingly engage in a system that is likely to allow them to receive insurance funds that they did not earn. Under the criminal health care fraud statute, public and private insurance are included. The False Claims Act specifically applies to public programs alone, however.
Types of health care fraud
While health care fraud can take many forms, several types are more common than others. These include the types of schemes that are detailed below.
Billing for services that weren’t provided
Health care providers engage in this type of health care fraud when they submit bills for services that were never provided to federal government programs like Medicare or Medicaid or to private insurance companies. Health care providers might engage in this type of fraud by using the real information of a patient who was not treated or by billing for extra services that a treated patient did not receive.
Upcoding occurs when a health care provider bills for more expensive medical services than what was actually provided. In some cases, a medical practice will also use a diagnostic code for a more serious medical condition than what the patient actually has to cover up the reason for billing for more expensive services.
Performing unnecessary procedures
Performing unnecessary procedures happens when a provider provides a treatment that a patient does not need. This form of fraud can include anything from performing additional lab tests that are unnecessary to performing extensive, unneeded surgeries.
Misrepresentations of non-covered treatments
In this form of health care fraud, providers perform non-covered treatments and then bill for treatments that are covered. Normally, the billed-for treatment will be in the same area as the actual treatment. This type of health care fraud is rarely done by accident.
A doctor may engage in falsely diagnosing patients in conjunction with billing the government for unnecessary services. A false diagnosis might be made to try to justify the unneeded services to obtain more money.
In overcharging schemes, medical providers bill patients for more than what they should be charged. They might charge copays that are not owed or for more money than what the actual copays should be under their insurance policies.
Medicare and Medicaid have codes for certain multi-phase treatments. The individual treatment phases may add up to more than what a doctor might receive from billing under the single code. The doctor will then unbundle the treatment and bill for each step separately to obtain more money.
Billing for services provided by unqualified staff
In some cases, a medical practice may have unqualified staff perform services and then bill for the doctor’s time instead. This is both fraudulent and places patients at risk.
Patients who have copays might not think anything is wrong with a doctor waiving their copays. However, this is illegal. In many cases, doctors who waive patients’ copays also bill for fraudulent services to recoup their lost money from the government or the private insurance company.
Kickback schemes involve a doctor receiving kickbacks from another specialist for making referrals of Medicaid or Medicare patients. This corrupt practice is illegal and constitutes a type of health care fraud.
Penalties for health care fraud
Health care fraud may be prosecuted civilly or criminally. Qui tam relators can file civil lawsuits against their employers on the government’s behalf. If their lawsuits allow the government to successfully recover the money, the relators will receive monetary awards from 10% to 30% of the total amount recovered. Medical practices that are found to be civilly liable may face substantial penalties and restitution. Their practices may also lose their health care licenses and be permanently barred from participating in Medicare or Medicaid.
Criminal prosecutions of health care fraud can result in federal prison sentences of 10 years for each count. If a provider performed unnecessary services that resulted in serious injury or death, the provider might face up to life in prison.
Get help from an experienced qui tam attorney
Health care fraud is a pervasive issue that can potentially endanger patients. If you have inside knowledge that your employer is engaging in a broad fraud scheme against the government, you should talk to one of the experienced qui tam attorneys at Swartz Swidler. Call us today at (856) 685-7420 to schedule a confidential consultation.