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Healthcare Fraud

Blowing the Whistle on Healthcare Billing Fraud

What is Healthcare Billing Fraud?

Healthcare billing fraud happens when healthcare providers—including doctors, hospitals, and nursing homes—knowingly file incorrect claims.

The false claims may be submitted to patients or insurance companies. In most cases, however, the target is public programs such as Medicare and Medicaid. These programs don’t have the resources to audit every claim, so they rely on whistleblowers who work for these facilities.

Why are Whistleblowers Needed?

Whistleblowers are needed because Medicare and Medicaid must manage millions of claims every year. To investigate all of these claims would use up resources that are currently used to provide care.

To encourage the public to help prevent fraud, the government passed the False Claims Act (FCA). The FCA is one of the strongest laws governing fraud in the US. Those who defraud healthcare programs will often be charged using this law.

In addition to strong penalties, the FCA includes a special Qui Tam provision to allow the government to reward whistleblowers with a portion of any funds recovered.

If you assist the government by working as a whistleblower, you could claim a large reward. In the past, whistleblowers have been rewarded with millions of dollars for their roles.

How to Spot Billing Fraud

While it is difficult for the government to identify fraud, it is much harder for any facility to hide the fraud from the healthcare workers who deal with patients and fill out claims forms.

You have been asked to change details on completed claim forms: Unless there is an error, completed forms should not be changed before they are submitted. If you are being asked to change details on a regular basis, it may be because the changes are part of a fraud scheme.

You have been threatened with disciplinary action for asking that rules be observed: As part of their licensing, most doctors, nurses, and other caretakers are required to learn certain laws. If you have complained about laws that are not being followed, and as a result been threatened with disciplinary action, fraud may be taking place.

Limited opportunities for review: Many care centers have individuals or entire departments who are tasked with reviewing information to ensure compliance with the law. If the procedures of the care center prevent certain information from being reviewed by these departments, fraud may be taking place.

The Most Common Types of Billing Fraud

You may be able to spot specific kinds of fraud if you work in a healthcare facility. What follows are some of the most common types of billing fraud:

Billing for Services that were Never Provided

One of the most basic types of billing fraud is billing for services that are not provided. In these cases, the facility sends a claim for materials or treatments that were not used in the care of the patient.

Imagine a patient checks to an emergency room after a car accident. Dozens of different treatments may be used to stabilize the patient. If drugs that were never used were added to the stack of claims, it would be very difficult for the patient or auditors to prove it. This creates an opportunity for fraudsters.

Double Billing

Double billing is a type of fraud where multiple or recurring claims are sent for treatments that were only provided a single time.

Double billing can also refer to cases where the facility tries to collect from the same payment from patients, insurers, or public health programs at the same time. Each party receives a copy of the bill and believes that they are the only payer.

Unbundling Fraud

Unbundling fraud occurs when combinations of procedures are broken up into individual treatments. This matters because the government has set prices (and identifying codes) for many common procedures.

For example, fixing a wound often takes several different treatments. First, the wound has to be cleaned, then the stitching is performed. After the stitching is complete, the wound must be dressed properly. This is all considered a single treatment with one code. Breaking it into multiple claims (that are more highly paid) is a type of fraud.

Upcoding Fraud

Upcoding fraud is another common type of billing fraud that involves identifying codes. This type of fraud occurs when a doctor or healthcare provider administers a treatment but claims that they administered a more complicated or expensive one.

In past cases, this fraud has been committed in several ways. For example, some services offer rides to the hospital to help the elderly keep their appointments. While these rides were not for emergencies, some companies filed claims saying they were emergency ambulance rides.

This type of fraud can also happen at a smaller level. Colds may be reported as flu. Stitches may be reported as minor bone fractures.

How to Blow the Whistle on Healthcare Billing Fraud

If you suspect billing fraud is happening, you can help by reporting it.

If you can, gather and preserve any evidence that you can that the fraud is happening. Make sure that you do not violate any laws yourself by collecting privileged patient information. If you need assistance with this step, you should contact a whistleblower lawyer.

While you can choose to report fraud directly to the government hotlines:

Medicare Fraud Tipline: (800) 447-8477
Medicaid Fraud Tipline: (800) 286-3932

If you report fraud direct to the govnernment without representation, you will lose your ability to claim a potential reward from funds recovered. Attorney representation is required to file a qui tam claim and collect any potential bounty using the False Claims Act. Whistleblower lawyers focus their expertise on the FCA and help whistleblowers reveal fraud in healthcare, military contracting, and other areas that are managed with public funds.

Your whistleblower lawyers can help with the complete process of bringing these cases to trial and collecting the whistleblower rewards when the case is complete.