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5 Common Types of Healthcare Fraud and How to Report Your Suspicions

Dept. of Health & Human Services

The Department of Health and Human Services, along with the FBI and Department of Justice, is fervent in its endeavors to identify and eliminate healthcare fraud.
Image source: Wikimedia Commons

In terms of the federal False Claims Act, healthcare fraud ranks as one of the most commonly prosecuted crimes. In fact, the FCA has been effective in recovering billions of dollars on behalf of taxpayers from dishonest hospitals, pharmacies, doctors, and pharmaceutical companies. If you suspect healthcare fraud, you may be able to report your suspicions under the FCA’s qui tam provisions, which allow private individuals the opportunity to share their information with the federal government in exchange for a percentage reward of any ultimate settlement or verdict. The following are the most common areas of healthcare fraud of which you should be aware:

#5 – Kickback Schemes

Kickbacks are rampant in the healthcare industry. In general, it is unlawful for any doctor or medical facility to receive anything of value (e.g., cash, equity, or gifts) from another doctor, healthcare facility, pharmaceutical company, medical device manufacturer, or anyone else to refer patients at a certain rate, to meet a certain quota, to prescribe a specific medication, to use a particular medical device, or to make any decision that could be tainted by the offering rather than made based on experience and the client’s best interests. Examples of kickback schemes on which we have reported include admission quotas for emergency room doctors or equity stakes in certain facilities based on a doctor’s agreement to refer a certain number of patients to the facility per year.

#4 – Medically Unnecessary Services

Medicaid and Medicare can only reimburse for procedures or expenses that are medically necessary. If you believe your doctor is suggesting tests, procedures, imaging, or any other medical process that is only minimally related to your condition, or does not seem to be relevant to your treatment, the referral may be medically unnecessary and in violation of federal healthcare rules.

#3 – Failure to Charge Medicare and Medicaid Patients Properly for Prescriptions

In a recent case, a popular grocery-store pharmacy was found to be offering in-store discounts to customers not receiving Medicaid or Medicare coverage, while charging the government full price for the same medication for Medicare & Medicaid patients. This is a violation of program rules and can often result in a successful False Claims Act case against the pharmacy. Under the rules, a pharmacy must charge Medicare and Medicaid patients fair market value for the drugs, which should be the same amount charged to all customers.

#2 – Allowing Nurses and Staff to Perform Examinations

Under Medicare and Medicaid billing rules, certain procedures shall only be performed by a physician. An emerging trend, however, is to allow nurses or office staff to handle routine outpatient procedures while billing the government for the cost of the doctor’s time to perform the work. This is not only unlawful and considered a false claim, but could present real dangers to the patient in the event an inexperienced or undertrained staff member is conducting a complex medical procedure. If you are experiencing this in your doctor’s office, we encourage you to speak with a whistleblower attorney right away.

#1 – Upcoding

Probably the most common method of defrauding the government, upcoding involves billing for services that were either never rendered or billing for one service when a similar, but cheaper, service was actually provided. Similar to the practice described in #2 above, illegal upcoding often costs the federal government millions of dollars per case and can be easily detected through a thorough review of your bill. If you see suspicious charges that do not align with your actual visit, your doctor may be engaging in this sort of unlawful billing practice.

Contact a Whistleblower Attorney Today

The attorneys of Berger Montague have handled a wide range of healthcare fraud cases and encourage you to contact the office with any information you have of suspicious billing practices. To make an appointment, contact us today.

If you have discovered evidence of fraud committed against the government, you may be entitled to a substantial reward and the legal protections afforded to whistleblowers under state and federal laws. The attorneys at Berger & Montague are nationally recognized for their work in Whistleblower/Qui Tam actions. For more information or to schedule your confidential consultation, contact us online or call us at 888-647-9292.