Unfortunately, fraud is everywhere in today’s world. In cases of Medicare fraud, someone, often a healthcare provider, attempts to defraud the government and the Medicare system for their own financial gain.
Medicare fraud hurts patients, taxpayers, as well as the overall healthcare system. If you have inside information about improper attempts to claim government funds, speak up and help stop Medicare fraud in Boston. The Tycko & Zavareei LLP Boston Medicare fraud attorneys can explain your rights and potential rewards in doing so during a free legal consultation.
Medicare Fraud in Boston, MA
The majority of Boston Medicare fraud happens behind closed doors in billing offices or in non-patient-facing roles. Medical personnel and billing specialists may be in positions to spot illegal activity and attempts to defraud government funds.
While we like to believe that healthcare facilities and pharmaceutical companies are above suspicion, every year billions of dollars are defrauded from federal-funded healthcare programs. Often doctors and other healthcare workers may be equipped to report kickbacks or suspicious billing practices by their employers.
Common Types of Medicare Fraud
Medical procedures and services are billed to insurance through a process known as coding. Medical professionals use an alphanumeric code to ensure that activities are billed accurately. These codes are universal and are used to document procedures, diagnoses, medications, and more.
Upcoding refers to the practice of intentionally coding medical processes incorrectly in order to get a higher payout from the insurance company or the government program being billed. According to a 2021 study, the practice of upcoding to commit Medicare fraud has increased in the past several years. The Medicare system lost approximately $60 billion in one year due to the improper use of billing codes.
Phantom billing is the practice of billing Medicare for procedures not performed, medications not given, or services not received.
Double billing is when a health care provider bills Medicare twice or more for the same product or service when in reality it was performed only once.
False Diagnosis or Medically Unnecessary Services
Many types of Medicare fraud may affect patients indirectly. The system upon which they rely is being exploited and the resources that they need are spread thinner. However, medically unnecessary services are a type of Boston Medicare fraud that directly affects patients and the standard of care that they receive. When surveyed, doctors registered with the American Medical Association said that they would consider roughly 20% of overall medical procedures and treatment to be unnecessary.
Medically unnecessary services and false diagnoses may go hand in hand. A physician may perform tests that they have no reason to believe their patient actually needs, then diagnose that patient with a condition that they do not have in order to administer treatments that they do not need. The provider would then bill Medicare for the testing and the treatments in order to make a profit.
Who Can Report Medicare Fraud in Boston?
The people who are most likely to witness Medicare fraud are ordinary employees going about their days and doing their jobs. Staff members who check over documents and billing may notice discrepancies such as coding errors. They also may see coding or billing that does not match up with the treatments that they have seen provided to patients, or notice tests being ordered with no clear reason. Sharp-eyed employees can become suspicious when something is not right. For example, in a health care office, anyone from the nurses to the billing staff could all report potential Medicare fraud.
Boston Whistleblower Protections and Rewards
The federal False Claims Act (FCA) and the Massachusetts False Claims Act are the most important laws to know about when dealing with Medicare fraud cases in Boston.
Both laws impose penalties and consequences for those who submit false or fraudulent claims to the government for reimbursement. It also rewards and offers protection for those who expose fraud.
Under the federal and state False Claims Acts, a Boston whistleblower’s anonymity is legally protected. At Tycko & Zavareei LLP, we have years of experience with Medicare fraud qui tam cases and will do everything in our power to keep your identity safe.
Additionally, the False Claims Act incentivizes those with insider information to come forward and give that information to the authorities so that the company or practice can be investigated. The law states that if a person provides information that leads to a successful lawsuit against a company committing fraud, then that whistleblower is entitled to 15 to 30% of the financial settlement that the government recovers as a result of the lawsuit.
How is Medicare Fraud Investigated and Dealt With?
When a whistleblower reports Medicare fraud, what are the next steps? The following is a breakdown of possibilities that may occur in a Boston Medicare fraud case.
- First, a whistleblower will bring their suspicions and any relevant evidence to a Boston qui tam lawyer. Qui tam is another term for the type of case brought under the False Claims Act.
- The lawyer will review all of the evidence and ask relevant questions. Then they will determine whether your suspicions are strong enough to launch an investigation.
- If the evidence is enough to produce reasonable suspicion, then the proper government authorities will conduct a quiet investigation. For the first 60 days, the investigation will be sealed to give the authorities enough time to look into the business or health care practice. This 60-day period may also be extended.
- If enough evidence is found during that investigation, then the government may decide to intervene in the case.
How a Boston Medicare Fraud Attorney Can Help
Not only are whistleblowers required under the False Claims Act to have a lawyer if they choose to pursue a qui tam case, but a qualified Boston qui tam lawyer will also be an excellent resource during the investigation. Speaking with someone who fully understands the False Claims Act and other laws that deal with fraud and whistleblowing can ease anxiety and give you a clear idea of where your case may be heading.
If you see something odd and decide that it is time to speak up, schedule a consultation with Tycko & Zavareei LLP today. We are here to help.