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Healthcare Fraud

Medicare Fraud: What it is and How to Report it

What is Medicare Fraud?

Medicare fraud is a broad term that covers any action that results in the defrauding of the Medicare public health insurance program. As one of the largest insurance programs in the US, it makes billions of dollars in disbursements every year to providers that include doctors, hospitals, pharmacies, hospices, and drug manufacturers.

The amount of money and transactions involved can make fraud tempting and difficult to detect. However, the government has many tools for detecting and reclaiming money lost to fraud—even years after the fraud was committed.

One of the ways the fraud is detected is through the use of the False Claims Act and the incentives that law offers to whistleblowers who are directly employed by the providers who receive Medicare funds.

How is the False Claims Act Used to Pursue Medicare Fraud?

The False Claims Act (FCA) is the federal law that makes it a criminal act to submit false claims to federal programs, such as Medicare. In addition to establishing stiff penalties for each instance of doctored reports, falsified records or other forms of fraud, the FCA provides financial rewards to whistleblowers through an included qui tam provision.

How Medicare Fraud Whistleblowers are Rewarded through qui tam

When a law has a qui tam provision, private citizens with knowledge of a violation are allowed to file a lawsuit on behalf of the government. If the case is successful, the whistleblower is allowed to claim a percentage of the funds that are recovered for the government.

Providers can defraud Medicare of hundreds of millions of dollars, even billions, before the fraud is detected. In the past, whistleblowers have been awarded amounts reaching nearly $100 million dollars. This amount may go to a single whistleblower or be divided up between several of them.

The Most Common Types of Medicare Fraud

Billing for Care not Provided

Fraudulent billing is one of the most common types of Medicare fraud, and it can involve several different practices, including falsifying invoices to charge the program for pharmaceuticals, treatments, and services that were never provided.

This type of fraud can happen more frequently in hospices and elder care facilities where the patients are unlikely to be able to reliably testify whether or not the services were provided.

Upcoding

Upcoding is a less common form of Medicare fraud that involves billing or performing services that are not medically necessary. It may involve the reporting of illnesses or symptoms that are not present in the patient. In most cases, the services are not performed, but when they are, they can be dangerous to the health of the patient.

Prescribing Unnecessary Medications

Prescribing unnecessary medications is another common form of Medicare fraud. Medicare will reimburse fully for many types of prescriptions, and this has led to some providers to attempt to provide as many prescriptions as possible per patient or place quotas on their doctors to prescribe.

It is considered one of the more dangerous fraudulent practices because the drugs must be moved out of the hospitals or pharmacy’s supply in order for the person committing fraud to cover their tracks. Sometimes, the drugs are destroyed, but in other cases, the prescriptions are taken and sold on the black market.

Providing or Accepting Kickbacks for Referrals

Kickbacks are considered a form of fraud against Medicare because they influence what decisions are made by care providers. The decisions doctors make when influenced can increase Medicare’s costs and lead to extra prescriptions and services when none are necessary.

Examples of Medicare Fraud Cases

‘Billing for services not rendered’ fraud claims were brought against the owners of what was then known as Dolson Avenue Medical—A chiropractic center. The charges were resolved in 2019 after several practice leaders were charged with fraud and conspiracy-related charges for billing for services not provided, double billing and other types of fraud.

Upcoding fraud and fraudulent service fraud claims were brought against Gateway Health Systems in Chicago in 2017. The government charges that the company falsely certified patients who were not homebound as needing in-home health services.

Kickback fraud claims were brought against Florida health executive Philip Esformes, and resolved in 2019. He managed dozens of Miami-Dade nursing facilities and was accused of paying bribes to convince doctors to refer patients to his nursing home network. It was one of the largest cases of Medicare fraud involving more than $1Billion.

How to Begin a Medicare Fraud Whistleblower Lawsuit

If you are aware of fraud against the Medicare health program, you may be able to claim a percentage of any funds that are recovered through a lawsuit. Fraudulent billing, upcoding, and kickbacks can be proven through records and established patterns of behavior. That may make Medicare fraud easier to turn into a case than other kinds of FCA-related fraud.

However, this does not change the fact that these cases are very complex. You need the assistance of-of a whistleblower lawsuit lawyer who can help you understand what it will take to bring the case and to win.

As a first step, you should schedule a consultation regarding your Medicare fraud claims. Time is of the essence. If someone files before you use the same information, you will lose your standing to sue. Certain types of fraud can also pass the statute of limitations within 6-10 years.