Medicare is a vital and widely utilized government program. It was signed into law in 1965 as a way for senior citizens to access healthcare through the money they had contributed to Social Security while they worked throughout their lives. Premiums tend to be lower than most health insurance options on the marketplace, and Medicare is accepted by over 90 percent of providers in the United States.
Unfortunately, the Medicare system is a frequent target of fraud, which impacts not only the government, but also taxpayers and patients as well. How does San Diego Medicare fraud happen, and how can everyday citizens put a stop to it? Meeting with a qui tam attorney at Tycko & Zavareei LLP is the first step.
The Basics of Fraud against the Government
Fraud, or deliberate deception with the goal of falsely obtaining money or benefits, is an unfortunately common practice. One of the most popular targets for fraud is the federal or state government, partly because it is a large entity, and bad actors assume fraud will go unnoticed.
The money that is lost in cases of fraud against the government comes from taxpayers. When someone defrauds the government, they are also effectively defrauding their neighbors and community. Any instance of fraud totaling over $1 million in governmental losses is considered “major fraud,” which is a serious crime.
Medicare in San Diego
Medicare is one of a few federal government healthcare programs, another widely known program being Medicaid. Medicaid is for citizens under a certain income threshold, whereas Medicare is for people over the age of 65. San Diego has a relatively large retiree population, and many of those retirees are on Medicare. Unfortunately, this provides ample opportunity for San Diego Medicare fraud.
How Does Medicare Fraud Work?
Though it is a form of theft, any type of fraud is more complex than simple theft. People who commit fraud use deception to conceal the fact that they are receiving money or benefits that they did not legitimately earn. When it comes to Medicare fraud specifically, practices or providers deliberately misrepresent the services, care, and/or medications they provide patients in order to collect money from the government under false pretenses.
There are several well-known tactics people use to defraud the Medicare system, some of which directly impact the care provided to patients. The following Medicare fraud tactics all involve deception for personal gain:
- Double billing: Billing Medicare for the same service more than once.
- Phantom billing: Submitting a claim to Medicare for services that were never performed.
- Incorrect coding: Medical services are billed using a universal alphanumeric code. A medical office is supposed to record the codes for the procedures or services provided and submit them to the Medicare office for reimbursement for the coded services. Since coding errors can and do happen, some people use this fact to disguise their attempt to code for more expensive services than they are providing.
- Medically unnecessary services: Fraudulent practices or providers may perform expensive procedures or tests that a patient does not genuinely need in order to collect a larger payout from Medicare. Besides potentially putting patients through mental stress, unnecessary procedures may even cause more issues down the line.
- False claims: Sometimes, a practice will submit a claim for a piece of equipment or some other upgrade, such as an MRI machine. The expense is then approved by Medicare, but the equipment is never purchased, and the practice or provider pockets the profits.
- Kickback schemes: Kickbacks are a sort of commission-based bribe. Pharmaceutical kickbacks are some of the most common kickback schemes, characterized by companies bribing providers to prescribe a particular medication regardless of whether or not it fits the patient’s needs. In exchange, the provider gets a “cut,” or a portion, of the profits from the prescription.
Signs of San Diego Medicare Fraud
Most whistleblowers are everyday employees who spot signs of fraud in their workplaces and decide to make a disclosure to a fraud lawyer under the False Claims Act. The False Claims Act is a federal law that protects whistleblowers from retaliation and provides rewards for information that leads to a successful fraud lawsuit on behalf of the government. Tycko & Zavareei LLP has led many successful qui tam lawsuits, serving justice on behalf of the government and fighting for maximum compensation for whistleblowers.
Medicare fraud can be hard to spot, since it is entirely based on deception, but there are signs that employees can watch out for. If you notice anything “off” in billing documents, such as procedures billed to patients who did not receive them, reimbursement for equipment that is nowhere to be found, or canceled appointments that were still billed to Medicare, consider bringing your concerns to a lawyer. Things that appear to be errors at first may in fact be purposeful deceit indicative of a larger pattern of fraud.
Reach out to a San Diego Medicare Fraud Attorney Today
The process of coming forward to stop fraud starts with a legal consultation. You will need to retain a Medicare fraud lawyer in order to move forward with a False Claims Act disclosure. They will evaluate the evidence you provide and determine whether it is sufficient to file a whistleblower lawsuit. If so, the paperwork will be filed through your lawyer to preserve your anonymity during the investigation of your claims.
Tycko & Zavareei LLP has been fighting fraud for years, securing millions of dollars in whistleblower settlements alongside our brave clients. Have you noticed Medicare fraud in San Diego? Fill out a contact form today to set up a free consultation with our accomplished attorneys.
