The Whistleblower Lawyer

How to Spot Medicare Fraud – and Why It’s Such a Big Problem 

Healthcare Fraud Lawyer

Medicare and Medicaid fraud are on the rise, and this problem is becoming a costly one for everyone involved. From patients seeking medical care with Medicare to the doctors receiving Medicare payments and the taxpayers who are footing the bill, Medicare fraud is a serious problem that needs to be addressed. Without change, Medicare costs will continue to increase, as will taxes, which is a bad situation for everyone.

A Problem That Continues to Grow

According to the Center for Public Integrity, in 2016 around $16.2 billion in improper payments to private Medicare Advantage health plans were made. If that number were not bad enough, overpayments for standard Medicare programs added up to $60 billion dollars that same year. The fact that this number is almost twice the amount the National Institutes of Health spends on medical research each year shows just how extensive this fraud problem is.

Those numbers are actually quite staggering, because that money comes directly from taxpayers. Continued waste in Medicare and Medicaid could end up bankrupting these critical services, leaving needy people without the medical services they desperately require.

So where is all of this wasted money going? Fraud, waste, abuse and improper payments are all at fault for the wasted funds. One particularly bad problem is the more than 23,000 fake or bad addresses currently on Medicare’s list of health care providers. Many of these addresses are still being used to collect Medicare payments. Researchers found instances of payments being sent to rented mailboxes and even restaurants, in spite of the fact that Medicare regulations say payments need to be delivered directly to the address where the doctor is practicing medicine. Because Medicare does not monitor these addresses, fraudulent payments continue to go out, being collected by others and adding to the waste in the current Medicare system.

Signs of Medicare Fraud and Abuse

These examples show just how extensive and expensive Medicare fraud can be, but sending Medicare payments to wrong addresses is just one example of the types of fraud and waste that occur. In order to stop this costly problem, people need to be able to spot signs of medical Medicare fraud so they can draw attention to it and put a stop to it.

In addition to the fraudulent addresses, other examples of Medicare fraud include:

  • Submitting false claims or misrepresentations to the Medicare system in order to get payment
  • Soliciting or adding referral rewards for services that the Medicare program reimburses the doctor to offer
  • Making any referrals for designated health services that are prohibited under the Medicare program
  • Billing for Medicare appointments that the patient canceled or did not show up for
  • Billing for more complex services than delivered to the patient
  • Billing for services or supplies not used or provided
  • Falsifying records in order to get a larger payment for a service.

Medicare abuse is another problem. These are less obvious problems, but they do add to costs to the program. Abuse may include:

  • Delivering and billing for unneeded medical services
  • Charging excessively high prices for covered services or supplies
  • Using codes inappropriately to increase the overall bill for services (upcoding).

Under the False Claims Act and several other laws, these actions are illegal, and the companies or medical service providers who do them need to be held accountable. Not only that, but these continued abuses of Medicare are going to cause substantial problems in the future for a much-needed system. Employees who spot or suspect fraud from their employers can help put a stop to these actions through whistleblowing.

By filing a lawsuit on behalf of the government against a dishonest employer, whistleblowers can help put a stop to these actions, helping lower overall healthcare and tax costs for everyone.

What to Do if You Suspect Medicare Fraud and Abuse

If you suspect that your employer may be guilty of Medicare fraud or abuse, you have the right to take action to put a stop to it, without fearing for your job. The False Claims Act actually sets up a program to reward whistleblowers when Medicare or Medicaid fraud is reported and stopped. In fact, you can collect between 15 and 30 percent of what the government is able to recover when you are acting as a whistleblower, and your employer is not able to retaliate against you for your actions. If they do, you can partner with a whistleblower attorney to hold them accountable and protect your job.

So what can you do to stop Medicare fraud and abuse and take advantage of whistleblower protections? First, talk to a whistleblower attorney who has experience with Medicare fraud cases. This will be the best way to ensure you are getting adequate protection as you move forward. An attorney will also help you with the whistleblower lawsuit process, should you decide to pursue that option.

To be successful in a whistleblower case, you will need to have ample evidence to establish the suspected fraud as fact. If you suspect that your employer is upcoding, for example, you are able to gather evidence from patient records and share those with your lawyer to show the instances of fraud. Current laws allow for this without putting you in violation of HIPAA regulations. This is just one example of a way in which you can collect evidence, and your attorney will help you find other legal ways to do so.

Once you have enough evidence, you have several options. One is to file a complaint internally to see if that is sufficient to stop the action. Second, you can file a complaint with the Office of the Inspector General through the Department of Health and Human Services. This option can open an investigation into your employer that may stop the fraud. Third, you can file a lawsuit on behalf of the government as a whistleblower and protect yourself against retaliation. Your attorney will be able to advise you as to which of these options is best.

Becoming a whistleblower requires the guidance of the right attorney. The Louthian Law Firm can help you understand your rights and options. As a law firm with a strong focus on whistleblower cases, we are well equipped to help you understand the next steps in your case. Should you choose to file a claim, the firm can help you craft a claim that is clear, concise and accurate. This will help ensure you are properly protected and that your claim gets heard. For a free, confidential consultation to discuss your case, call the Louthian Law Firm at 1-877-710-5618 or fill out our online contact form.

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