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Healthcare Fraud

Healthcare fraud is a top priority of the United States Department of Justice’s enforcement efforts under the False Claims Act. Over a recent four-year period, 80% of the $11.4 billion recovered by the Department of Justice under the False Claims Act was in healthcare fraud cases. Those cases involved fraud in the Medicare, Medicaid and other taxpayer-funded healthcare programs. The primary way the Department of Justice uncovered the fraud that led to these recoveries was from reports by whistleblowers. Over that same four year period, whistleblowers received more than $1.54 billion as their share of these recoveries.

If you have information about healthcare fraud, waste, or abuse taking place, get in touch with our legal team as soon as possible. We can offer invaluable guidance and insight on your journey as a whistleblower. The lawyers at Tycko & Zavareei LLP are well-versed in whistleblower claims and qui tam law, so do not hesitate to reach out to our firm today.

What is Healthcare Fraud, Waste, and Abuse?

Healthcare fraud, waste, and abuse encompass many fraudulent practices, including:

Healthcare fraud, waste, and abuse occur when healthcare providers such a physicians, nurses, at-home caregivers, and nursing home staff lie to insurers or the government, endangering patients and ultimately hurting taxpayers in the pursuit of profits. Any medical staff member and healthcare facility that attempts to defraud government-funded health insurance programs could be on the hook for healthcare fraud under the False Claims Act.

Common Types of Healthcare Fraud

Upcoding & Unbundling

Medicare and Medicaid offer healthcare providers reimbursement for medical services and procedures rendered to and performed on patients. Healthcare providers are responsible for reporting what services were rendered to a patient using “codes” that indicate to insurance how much to reimburse for the cost of the care. Upcoding occurs when a healthcare provider reports a code for a procedure that is more expensive and which was not actually performed. They do this to receive more funds from Medicaid and Medicare than they are actually owed.

Similarly, some medical services should be bundled together when reporting to Medicare or Medicaid, but unscrupulous healthcare providers may engage in unbundling fraud when they deliberately separate those services and bill for them individually. Unbundling services and procedures that should have been cheaper when charged together can lead to bigger bills for patients, too, who are responsible for copays. Anyone with information about upcoding and unbundling should connect with a diligent healthcare fraud attorney on our team for guidance on what to do next.

Billing for Unnecessary Medical Services

A healthcare provider may offer false diagnoses or order tests and procedures which are not medically necessary to address a patient’s condition in order to garner more funds from Medicare and Medicaid. The dangerous distinction between this type of healthcare fraud, also known as “phantom billing,” and upcoding is that the patient is at risk of suffering additional harm. Doctors and hospitals who perform and bill for unnecessary medical services put their patients’ needs second to profits and endanger their health, making it crucial for whistleblowers with information on phantom billing to come forward.

Charging Personal Expenses to Medicaid

Nursing homes and long-term care facilities must submit an annual cost report to receive reimbursement from Medicaid and Medicare. The administrators of assisted living facilities commit healthcare fraud when they include personal expenses in these cost reports. An example would be when a nursing home administrator includes the cost of their personal vehicle on the report. This kind of healthcare fraud is considered a crime and could lead to criminal prosecution.

Kickback Schemes

Individuals who refer patients to a particular hospital or doctor may unlawfully accept payment for the referral in what is known as a kickback scheme. “Kickbacks” are unfortunately common in healthcare fraud cases. Examples of kickback schemes include when a doctor accepts money in exchange for patient referrals or refers patients to a facility with which they share a financial relationship. Kickback schemes are an example of federal healthcare fraud and may be prosecuted at the federal level.

Nurses and Staff Performing Exams

Medicare and Medicaid billing rules require certain procedures to be performed by a physician only. However, more and more hospitals are allowing nurses or other medical staff members to perform procedures while billing for the cost of a physician’s time. This violates the False Claims Act and could endanger patients if an inexperienced or undertrained staff member performs a complex medical procedure. If you experienced this firsthand or have first-hand knowledge of it occurring at your place of employment, do not hesitate to reach out to one of our dedicated healthcare fraud attorneys.

Double Billing

Healthcare providers engage in double billing when they obtain payment or reimbursement for the same service multiple times. For example, billing a private insurer while receiving payment from Medicare or Medicaid, or billing twice for a service that was only performed once would constitute double billing. Anyone with information concerning fraudulent billing by a healthcare provider is encouraged to work with one of our lawyers to ensure their rights as a whistleblower are vehemently protected.

Why is Healthcare Fraud Harmful?

The consequences of medical fraud cannot be understated. Outcomes of healthcare fraud include increased insurance premiums, increased taxes, and patient exposure to unnecessary medical procedures. All outcomes affect everyday people and patients, and patients who suffer additional harm as a consequence of healthcare fraud will continue coming back for medical treatment, further incentivizing unscrupulous medical professionals to continue engaging in fraudulent activity.

How to Report False Medical Billing

The best ways to report false medical billing are to hire a lawyer. An attorney can help you anonymously report a healthcare facility and ensure your rights as a whistleblower are protected. A lawyer would understand the ins and outs of filing a whistleblower claim, including what deadlines and legal protections apply in a given health care fraud case.

False Claims Act Whistleblower Protection

If your reporting of healthcare fraud leads to the recovery of defrauded funds, you may be entitled to a reward under a whistleblower law called the “False Claims Act.” The False Claims Act also protects employees who blow the whistle on fraudulent activity taking place at their jobs from being demoted, suspended, terminated, threatened, harassed, or otherwise discriminated against in retaliation.

Whistleblowers who do experience workplace retaliation after blowing the whistle on healthcare fraud may seek reinstatement to their previously held position, twice the amount of missed or unpaid wages plus interest, and compensation for special damages such as emotional distress and attorneys’ fees. A case for unlawful retaliation by an employer may be brought with or separately from a qui tam lawsuit filed under the False Claims Act.

Can a Healthcare Whistleblower Remain Anonymous?

Healthcare fraud whistleblowers who file qui tam cases under the False Claims Act may begin their claims anonymously. Specifically, the False Claims Act allows whistleblowers to remain anonymous until the government completes its investigation into the fraud they reported. If the government finds evidence of healthcare fraud based on your tip, you would be required to disclose your identity for further proceedings.

Hiring a Healthcare Whistleblower Lawyer

If you have knowledge of any signs of health fraud, waste, or abuse in the Medicare, Medicaid, TRICARE, Veterans, or Federal Employees Health Benefits (FEHB) programs, your information could lead to the recovery of substantial funds and entitle you to a significant financial award. The Department of Justice has recovered BILLIONS of dollars in healthcare fraud thanks to ordinary individuals like you who report medical fraud, waste, and abuse.

There are also protections for whistleblowers who have already reported the fraud to their employer and were retaliated against as a result. You can tell us about the information you have during a free consultation at our firm. Complete the short contact form and an attorney with Tycko & Zavareei LLP will promptly get back to you.

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