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The Top 10 Illegal Health Care Schemes

Healthcare FraudMost medical practitioners are honest, caring persons doing their part to keep us all healthy. Only a few dishonest ones want to fatten their bank accounts by committing fraud, but there are enough of them that Medicare, Medicaid, and TRICARE taken together are an enormous source for whistleblower cases brought under the False Claims Act (FCA). Our national spending on these programs amounts to around $2.7 trillion dollars, and fraud is estimated to rob us of roughly 10 percent of that amount–$272 billion. At the end of 2013, over 2,000 fraud probes for health care were in progress.

In some ways, fraud is fraud; the fundamental wrongdoing at the bottom of many health care swindles resembles other types of fraud. But the specifics of how the cons are perpetrated may not be as familiar to you. If you work in the health care industry where Medicare, Medicaid, or TRICARE patients are served, and if any of these schemes ring a bell, you might consider whether you have cause to become a whistleblower. That’s because all of the following activities are illegal under the FCA.

Here are 10 of the most common health care fraud schemes for you to mull over:

  1. Billing for services that were never provided. This type of false claim may be the most common one of all. A little creative accounting is all that is called for in the mind of the fraudster, so it may seem easy to get away with. Examples of such fraud include services not performed during a legitimate visit, or even charging for visits that never happened. Those who put in such claims are often caught because they do not provide the backup information and supporting documentation that routinely occurs during any medical appointment. Occasionally, this type of false claim is the result of medical identity theft. In such cases, the person for whom claims are filed may never have been a patient of the medical office in question.
  2. Billing a non-covered service as a covered one. At first glance, this could seem to be beneficial to patients, because insurance would pay for something deemed medically necessary that is not covered. But, more often than not, such falsely billed services are not medically necessary, nor are they standard. One example would be cosmetic surgery to make a nose appear more attractive (not covered) while billing it as a deviated septum repair (covered). Another example could be an experimental treatment that is billed as a medically-standard one.
  3. Upcoding, or submitting billing codes for more expensive procedures or services than were provided. Reimbursement these days hangs on what are called billing codes, often called ICD-10 codes. One example might be a simple check-up that is upcoded as an expanded check-up so that the doctor is reimbursed for a greater amount.
  4. Unbundling, or billing each step of a procedure as if it were a separate entity rather than part of a whole. One example would be a hysterectomy for which the doctor is paid a certain amount. If a doctor submits claims for each part of the surgery separately (abdominal exploration, ovary removal, uterus removal, adhesions removal, and so forth), they can often receive far greater payment.
  5. Kickbacks, or accepting some form of remuneration in return for compensation or consideration, are secret agreements which can be difficult to uncover. Remuneration can mean cash, cars, vacations, or other compensation. Consideration can be directing patients to use a particular medical provider, such as a specific dialysis center, hospital, or specialist. Kickbacks are covered by laws such as the Anti-Kickback Statute and the Stark Law and are, except in extremely rare instances, completely illegal.
  6. Listing false dates of service. This false claim can occur when a medical professional sees a patient for more than one problem during a single visit. In order to gain more remuneration, they put in false claims for two or more office visits on different dates rather than put in claims for multiple problems on the same date.
  7. Misrepresenting the service provider. This could be a situation in which a service is actually performed by a practitioner whose rate of reimbursement is lower, but the claim is submitted for a practitioner who carries a higher rate of reimbursement. One example would be routine wound care provided by a nurse-practitioner, but that is billed as if a medical doctor performed the service.
  8. Performing medically-unnecessary procedures or services for the sole purpose of submitting claims to generate payments. Some diagnostic services are known to have a greater chance of being unnecessary than other types. At its worst, such fraud can lead to procedures, such as for angioplasty or implanting a cardiac device, which are not only unnecessary but also dangerous to the patient.
  9. Creating a false diagnosis in order to medically justify diagnostic tests, medical procedures, and surgeries in order to submit claims that will be reimbursed. Often, such fraud amounts to diagnosing a similar disease that has higher reimbursement rates or a greater number of reimbursable tests or procedures, such as diagnosing a spinal disease or pain syndrome when the problem is actually a common backache.
  10. Prescription and pharmacy fraud. Such fraud can run the gamut from physicians who operate “pill mills” for addictive painkillers, to pharmacies that do not perform due diligence in checking a physician’s DEA number to validate a prescription, to pharmacies submitting claims for prescriptions filled for nonexistent customers. Often, the latter types of claims will be for low-dollar drugs, because multiple small claims don’t draw as much attention as fewer large ones.

Fraud seemingly goes on and on. In one more extreme example, an anti-fraud investigator wrote about Alzheimer’s patients who were seated in front of a movie for a couple of hours, with the facility billing that time as “group therapy.” But think about this: for us to know about that example, someone had to discover it and then report it. Often, reporting falls to the whistleblower, because the government simply does not have enough help to investigate all fraud on their own. If you work in the healthcare industry, make it your business to know the common schemes in case you should ever run across one.

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.

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