There is no question that healthcare costs in our country are growing at a much faster rate than that of inflation. You know this well if you have recently paid a medical bill or a premium for healthcare insurance. One of the reasons costs are rising is simple: an abundance of Medicare fraud. In 2014, according to the Centers for Disease Control and Prevention (CDC), our national health care bill amounted to a total of $3.0 trillion, with a per capita expense of $9,523. Our health care expenditures as a nation now amount to 17.5 percent of our Gross Domestic Product (GDP).
The National Heath Care Anti-Fraud Association believes that a conservative number for the amount of our total national healthcare fraud is 3 percent. That’s $90 billion lost through fraud in 2014. And some think the fraud percentage runs as high as 10 percent, which would mean $300 billion lost.
Fraud involving Medicare fraud and Medicaid fraud are estimated to tack on almost 10 percent to the total costs of those programs, according to the New York Times. In 2013, only $4.3 billion was recovered from an estimated $60 billion in fraud.
It’s clear we need all the help we can get, and that includes from whistleblowers.
What Does Medicare Fraud Include?
Medicare fraud typically involves deliberate false activity, such as:
- Submitting false statements or misrepresentations in order to obtain federal health care payment for which no payment would normally exist. For example: billing for services not actually provided, such as for medical tests that were never run.
- Soliciting, accepting, or providing any form of compensation which would expedite a transaction involving services or things in the hopes of gaining federal health care financial reimbursement. Doing so is also known as engaging in kickbacks, which are illegal under the Anti-Kickback Statute. For example: accepting an expensive gift such as a vacation or automobile in exchange for steering patients to a specific provider.
- Making certain kinds of forbidden referrals for health services that benefit the referrer. For example: violating the Stark Law, or Physician Self-Referral Law. This law regulates Medicare and Medicaid patient referrals and prohibits a physician from receiving any form of financial gain for referring a patient for tests or other medical services. For example: referring a patient needing dialysis to a specific entity in which the doctor has a financial stake.
Other forms of fraud include bribing someone for their Medicare number, or stealing someone’s number, in order to create false claims and gain reimbursement.
What Constitutes Medicare Abuse?
Medicare abuse involves activities that directly or indirectly create unnecessary costs for the federal program. Abuse can range from mistakes to errors due to inefficiencies and bending the rules. Examples of abuse are:
- Billing for new medical equipment but providing used equipment, or billing for more-expensive new equipment while providing less-expensive new equipment.
- Upcoding (assigning incorrect billing codes for the purpose of gaining a greater payment from Medicare).
- Unbundling (breaking a complete service into smaller components to create more claims for the purpose of gaining more payments from Medicare).
- Using different codes to charge more than once for one service or treatment.
- Seeking reimbursement for substandard care in facilities such as nursing homes or rehabilitation centers.
- Running tests that are not medically necessary.
- Running duplicate tests because of mistakes or inefficiencies.
Unbundling and upcoding are two fairly common ways that providers defraud Medicare.
Halting Fraud in Its Tracks
We do have some weapons in the fight against fraud, such as the Department of Health and Human Services (HHS) and Department of Justice’s (DOJ) anti-fraud unit named the Health Care Fraud Prevention and Enforcement Action Team (HEAT). Through HEAT, over 1,500 defendants who stole over $5 billion were brought to justice. In 2015, HEAT was responsible for taking down a fraudulent billing scheme amounting to $712 million.
But stopping Medicare fraud also relies on whistleblowers, despite organized federal programs such as HEAT. Suits brought under the qui tam provisions of the False Claims Act, which provides the means for individuals to sue on behalf of the government for false claims, have been responsible for the following whistleblower wins:
- Three employees brought down fraudulent doings at Adventist Health Systems in Florida to the tune of a record-busting $118.7 million. The whistleblowers’ share, which would amount to between 15 and 30 percent, is not known at this time.
- In South Carolina, allegations of fraud against Nason Medical in Charleston were filed by former employees. The settlements totaled over $1 million.
- Labs in Virginia and California that ran heart disease tests settled for $48.5 million because of whistleblower actions. Among the whistleblowers was a doctor from Hilton Head.
We urge you to contact us at the Louthian Law Firm if you think you have evidence of fraud. Help us all save countless billions and make fraudsters pay.
Making a Difference.
If you think you have the facts needed to bring a whistleblower case, the experienced whistleblower attorneys at the Louthian Law Firm can review your case and help you file the appropriate disclosure statement. Under some circumstances, the government will intervene, or join in your lawsuit.
Your chances of succeeding are greater if your whistleblower claim is substantive, clear, and to the point. Because of this, meeting with a qualified whistleblower attorney can increase your chances of winning. The Louthian Law Firm can help you form your claim so that the government will be more inclined to intervene in your case; government intervention can sometimes increase the chances of recovering reward money. Even if the government decides not to intervene, it could still be a good idea to pursue your case without government involvement. Our strong support system can assist you through every step of the process.
For a free, confidential evaluation of your case, call the Louthian Law Firm today at 1-803-454-1200 or, if you prefer, you can fill out our online contact form.