The federal healthcare system is in place for a simple reason: to make sure that American citizens have fair access to healthcare regardless of their age or income. Medicare and Medicaid are each in place for a different segment of the population, with Medicare covering people ages 65 and older, and Medicaid covering those below a certain income bracket.
Though these programs exist to help people, there are certain organizations and individuals who seek to take advantage of the system for their own gain. Medicare fraud in Miami cheats not only the government, but also the individuals who rely on Medicare to access their healthcare.
How Does Medicare Fraud Happen?
Medicare fraud happens more often than one might think and comes in many forms. Medicare fraud can happen in a number of ways, most of them having to do with falsifying billing information. Here are a few common Medicare fraud schemes in Miami:
- Double billing – One of the simplest forms of Medicare fraud is billed to Medicare twice for the same services.
- Unnecessary treatment or false billing – In order to receive a payout for high-value services, a healthcare practice may either claim that they were performed when they were not or perform them regardless of need. An example of unnecessary treatment would be if a patient came in with a normal migraine headache but was given an unnecessary MRI. The treatment would still make sense to the patient when explained but serve no purpose other than producing a profit.
- Pharmaceutical kickbacks – Physicians are sometimes approached by pharmaceutical companies willing to give them a financial or material reward in exchange for prescribing a particular medication. These rewards are called kickbacks, and they often lead to patients being prescribed more expensive medications which may not fit well into their treatment plan.
- Upcoding – All healthcare providers use a universal alphanumeric coding system to bill medical treatments and procedures. Upcoding is the practice of purposefully entering the wrong codes while billing in order to receive higher payouts from Medicare. Codes for more expensive procedures are entered and billed to Medicare, regardless of the treatment the patient actually received.
Medicare Fraud in Miami
South Florida, including Miami, is a hotspot for Medicare fraud. Philip Esformes, sometimes referred to as the “king of Medicaid fraud,” was the owner of more than two dozen skilled nursing home facilities across Florida. Esformes managed to defraud the government of over $1 billion by accepting numerous kickbacks, moving patients and readmitting them in order to claim more benefits, and providing medically unnecessary treatments to patients.
Florida state law protects people who blow the whistle on risks to “the public’s health, safety, or welfare.” Since Esformes’ actions endangered the patients in long-term care facilities, who were members of the public, a whistleblower would have been protected from retaliation. However, Esformes was able to get away with defrauding over $1 billion until he was eventually caught, in part because no one came forward. A whistleblower’s information may have helped to stop him sooner. Tycko & Zavareei LLP specializes in working with whistleblowers to stop Medicare fraud in Miami and elsewhere.
How Miami Nursing Homes May Commit Medicare Fraud
Nursing homes and assisted living facilities in and around Miami provide long-term care for people who are aging or ill. Due to the age and mental or physical impairments that someone in a nursing home facility may have, many residents depend on Medicare to receive healthcare.
In skilled nursing facilities, residents with healthcare though Medicare are evaluated using the RUG (resource utilization group) scale. It is used to place Medicare patients into groups based on the level of care and resources they need, with higher levels of care corresponding to higher groups.
Medicare then reimburses skilled nursing facilities with a set amount based on each patient’s RUG group, with higher groups netting more reimbursement for the facility. In order to receive more funds from Medicare, nursing homes may change residents’ treatment to fit them into a higher group regardless of whether that treatment is right for them.
Stopping Medicare Fraud in Miami
The ability to stop Medicare fraud in Miami rests with everyday people. The government cannot be everywhere at once and witness all instances of fraud as they happen. Instead, they rely on the eyes and ears of people who witness it day-to-day, usually employees who notice something “off” in the workplace.
The signs of fraud can be subtle, like your boss evading or providing short, vague answers to certain questions about finances or billing. They can also show up as patterns, like consistent coding errors that always seem to benefit the practice in some way. Either way, employees have the ability to notice when something is out of the ordinary for their workplace, whereas on paper it may look completely normal.
Those who notice signs of potential fraud should speak with a Medicare fraud lawyer in Miami, like those at Tycko & Zavareei LLP, as soon as possible.
Contact a Medicare Fraud Lawyer in Miami Today
The decision to blow the whistle on fraud can be a scary one, but the condition of anonymity lessens the fear for many. The False Claims Act, which is the primary federal law relating to whistleblowing, requires whistleblowers to retain a Medicare fraud whistleblower lawyer and file paperwork through their attorney in order to protect their identity.
Tycko & Zavareei LLP has been working with whistleblowers in Miami under the False Claims Act for years and will do everything in our power to protect you during your case. Contact us today to schedule a free and confidential consultation.
