Medical fraud in all its forms is a big business—a big, crooked business. Because of that, the False Claims Act (FCA) is used to bring down those who would illegally benefit from the government health care programs Medicare, Medicaid, and TRICARE. Other health care wrongdoing that touches on these federal programs can also be subject to FCA prosecution.
But the government simply does not have enough investigators to take down the criminals, and besides, many of the scams that are run are best discovered from the inside. For that reason, the qui tam whistleblower provisions of the FCA greatly help to root out fraud. A qui tam suit means that an individual can sue on behalf of the government, and receive between 15 and 30 percent of any settlement or proceeds recovered. The government depends on employees and other associates to blow the whistle, bringing to light any fraud they may discover.
Medicare fraud, depending on the violation, can be more widespread than you think. Here is a partial list of some of the more common kinds of fraud:
- Billing for the same service more than once (often accomplished with different ICD codes)
- Billing for medical services that are not medically necessary
- Billing for nonexistent services or medical equipment
- Running tests not ordered by a doctor and billing for them
- Upcoding (using billing codes that don’t accurately reflect the medical problem in order to gain a larger reimbursement)
- Unbundling (breaking down a service into components in order to submit separate claims in order to gain a larger reimbursement)
- Diagnosis-related-group (DRG) fraud, which can include upcoding and unbundling
- Violating the Stark Law, which prohibits any inappropriate financial ties between medical professionals or entities that might influence patient referrals
- Receiving or providing kickbacks (illegal payments or goods meant to influence a medical professional’s choice of drug, treatment, etc.). The Anti-Kickback Statute prohibits such payments.
- Billing for new medical equipment when the patient is given used goods, or billing for more expensive equipment when the patient receives a less-expensive kind
- Failing to report and/or return a Medicare overpayment
- Misrepresenting dates or locations of service for the purposes of fraudulent claims
- Billing for a non-covered service as a covered service
- Bribing someone to obtain their Medicare number in order to submit false claims
- Seeking Medicare reimbursement for any substandard care, but especially in skilled nursing centers, long-term-care facilities, or nursing homes.
The ways that Medicaid can be defrauded are basically the same ones that are common to Medicare. One interesting difference between the two programs is that Medicare is one large federal system, while Medicaid is administered by each of the 50 states, which can make it hard to uncover and track fraud and abuse.
However, even though the federal government gives each state’s Medicaid program some matching funds to provide enforcement against fraud, the responsibility rests with each state to protect their Medicaid program.
Because federal money is involved, qui tam cases can be brought under the FCA for Medicaid fraud.
TRICARE, formerly known as CHAMPUS, is part of the US Department of Defense and administers the healthcare provided to certain military professionals and their families. However, an intermediary that contracts with TRICARE processes the healthcare claims that TRICARE providers and beneficiaries submit.
The ways that TRICARE can be defrauded are basically the same ones that are common to Medicare. And, because federal money is involved, qui tam cases can be brought under the FCA for TRICARE fraud.
Other Medical Fraud Areas
Other kinds of medical fraud exist that involve federal money and health care programs, producing situations where whistleblowers can step forward. Some of these areas include:
- “Big Pharma” Fraud
- Health insurance fraud (often involving Medicare Advantage and, to a lesser extent, Medicare supplement, or “gap” plans)
- Health insurance exchange fraud (involving the Affordable Care Act of 2010)
- Hospital fraud
- Durable medical equipment (DME) fraud
- Ambulance fraud
- Skilled nursing, long-term care facility, and nursing home fraud
- Home healthcare fraud
- Hospice fraud.
Did You Know That . . . ?
- From 2009 through 2015, nearly $16.5 billion in healthcare fraud was recouped by the US Department of Justice?
- Nearly $2 billion was recovered under the FCA for healthcare fraud just in the year 2015?
- From 2000 to 2010, pharmaceutical company false claims cases made up 25 percent of all FCA cases brought?
- From 2009 through 2015, for all qui tam whistleblower settlements and judgments (not just health care), the U.S. recovered $19.4 billion, with the awards to the whistleblowers totaling $3 billion?
- In 2015 alone, 638 qui tam whistleblower suits were filed in all areas of fraud (not just health care)?
- In 2015 alone, over $2.8 billion was recouped for qui tam whistleblower settlements and judgments (not just health care), with $597 million paid out to whistleblowers?
- There is a Medicare Fraud Strike Force that was established in March, 2007, that operates in nine high-fraud areas?
- There is a federal interagency task force called the Health Care Fraud Prevention and Enforcement Action Team (HEAT), formed in 2009, which exists to coordinate and improve anti-fraud enforcement?
- Miami, Florida, has been called “the capital city of medical fraud”?
- In 2013, a mental health clinic owner was sentenced to 30 years in prison for false billing?
As you can see, medical fraud in all its forms runs rampant in our country. But enough facts and figures. Just remember this: We hope that, if you think you have actionable information involving medical fraud, you will call the people who make a difference every day of the week—the whistleblower attorneys at the Louthian Law Firm. Put your case in our capable hands.
Infographic: Healthcare Fraud and Whistleblowers in the U.S.
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Blowing the Whistle? We Can Help You with Your Next Step.
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.