WHAT IS MEDICARE FRAUD?
Medicare is a government insurance program for individuals who are over the age of 65-years-old or people living with certain types of disabilities or illnesses. Medicare fraud occurs when healthcare providers and institutions bill the government for services or supplies that have not been provided. This overcharging or unscrupulous billing costs taxpayers hundreds of billions of dollars every year and have caused healthcare costs to consistently rise. By some accounts, Medicare fraud accounts for more than twenty percent of total government spending on healthcare, over $200 million each year. Medicare whistleblowers have helped the government recover billions of fraudulent charges, but fraud perpetrated against the government is still rampant.
The government relies on whistleblowers and the False Claims Act to uncover Medicare fraud. In fact, most successful whistleblower lawsuits involve healthcare fraud or Medicare fraud. If you have evidence of past or ongoing Medicare fraud, you may be able to collect a substantial reward for reporting illegal conduct and bringing a case as a whistleblower.
If you are ready to blow the whistle on Medicare fraud, it is important to have an experienced attorney on your side. At Price Armstrong, our lawyers have extensive experience successfully representing Medicare fraud whistleblowers and protecting them from retaliation and abuse. Call us today at (205) 208-9588 for a free initial consultation and review of your case.
WHO CAN BLOW THE WHISTLE ON MEDICARE FRAUD?
Anyone who has uncovered Medicare fraud in a healthcare setting may be able to report this fraud under the False Claims Act, bring a qui tam action on behalf of the government, and be rewarded as a whistleblower. Most often, whistleblowers are Medicare coders, billing specialists, physicians, nurses, or accountants who work for a healthcare provider that is engaged in the fraud. Price Armstrong has represented brave individuals in a variety of healthcare roles who discovered Medicare fraud in the course of their employment.
In order to qualify as a Medicare whistleblower, you need to have inside or non-public knowledge of fraud, but you do not have to have been harmed personally. Changing laws and regulations can make reporting Medicare fraud difficult, and it is important to have an experienced attorney willing to protect your interests throughout the process and provide a confidential evaluation of your case.
HOW ARE WHISTLEBLOWERS COMPENSATED?
Whistleblowers who report Medicare fraud can be receive significant compensation for their efforts to combat fraud which continue to cost taxpayers billions of dollars. The False Claims Act establishes that whistleblowers are entitled to 15 to 25 percent of the government’s recovery. Given the number of Americans on Medicare and the vast resources devoted to healthcare, it is perhaps not surprising that Medicare fraud cases have constituted some of the largest qui tam recoveries in recent times. In 2015 alone, the federal government paid $597 million to whistleblowers who reported Medicare fraud. By reporting unlawful actions, not only you will be doing the right thing, but the government, in recognition of this public service, mandates that you be awarded a substantial portion of any recovery as a reward for the public service you have provided.
TYPES OF FRAUD AGAINST MEDICARE
- Billing for services not delivered (phantom billing) — This is perhaps the most common type of Medicare fraud and includes billing the government for services that were never given. Common examples include billing for x-rays, blood tests, and supplies that were never provided to the patient.
- Billing for unnecessary services — Some hospitals have fraudulently performed tests or procedures that are not medically necessary. In the worst cases, this type of conduct is not only fraudulent, it can endanger patient health.
- Falsification of patient records — Some providers may try to gain extra money by falsifying records to prove the necessity of more expensive procedures or surgeries. Medicare advantage risk adjustment fraud occurs when patients’ records are adjusted to make them appear in worse health, inflating monthly payments that the company receives per policyholder.
- Unbundling — This is the process of separately billing for services that should be combined to receive reimbursement from Medicare at a higher rate. When billing for services separately, the provider is usually able to receive higher payment. Unbundling, or “fragmentation” billing practices are fraudulent.
- Double billing — When a physician or hospital bills Medicare twice for the same service, this is known as double billing.
- Kickback fraud — The Stark Law prohibits kickbacks for patient referrals. This includes any entity with which a provider has a financial relationship (absent certain exceptions applying), and also applies to labs, medical providers, and pharmaceutical companies may offer illegal kickbacks or incentives for using their products or for referrals.
- Physician self-referrals — Federal law prohibits physicians from referring patients to themselves or to immediate family members.
- Upcoding — This refers to the practice of exaggerating services rendered to a patient. Medicare reimburses hospitals and healthcare providers at rates that vary with the type of treatment or procedure provided. Upcoding fraud occurs when a Medicare is billed with a code for a more expensive diagnosis or procedure than the patient actually received.
- Falsification of cost reports — Adding additional expenses or padding reports to Medicare is an example of falsifying cost reports. Personal expenses or costs necessary to run the healthcare setting are NOT able to be submitted to Medicare.
- Inflating medical spending reports — Health insurance providers commit fraud to escalate their Medical Loss Ratio by paying denied or excessive claims, misallocating revenue or falsifying medical expenses.
WHISTLEBLOWER LAWS RELATED TO MEDICARE
Both federal and state laws govern Medicare fraud and it can be treated as both a criminal and a civil matter, depending on the level of fraud. The specific laws that address healthcare fraud and protect whistleblowers from retaliation include:
FALSE CLAIMS ACT
The civil False Claims Act imposes fines for Medicare fraud of up to 3x the actual loss incurred by the program. The FCA also protects whistleblowers from harm and abuse during the process and offers them compensation for their work in uncovering Medicare fraud of up to 30% the amount recovered.
Paying others for referrals can be a crime in the healthcare setting. This statute forbids payment back to another doctor or healthcare provider for referring patients. Payment could include cash, meals, or travel. Both the person receiving the kickback and the one giving the kickback are both held liable under the Anti-Kickback Statute. Penalties include fines, prison time, and termination in the Medicare program. LEARN MORE>
This statute prohibits individuals convicted of crimes from participating in federal healthcare programs like Medicare. Excluded physicians cannot bill directly or indirectly for services rendered to Medicare patients.
This law forbids physicians from making referrals to themselves or to any immediate family member which has a direct investment. Self-referrals can be punished by exclusion from participating in federal healthcare programs, in addition to any monetary recovery. LEARN MORE>
PROTECTION FOR MEDICARE WHISTLEBLOWERS
If you are ready to report healthcare fraud in your workplace, it is important to know that you are protected by federal and state qui tam laws. Under the False Claims Act, you are protected from being harassed, fired, or reprimanded for your actions and compensated for the risks you take exposing misconduct.
Before you report Medicare fraud, consult the Medicare fraud attorneys at Price Armstrong. Your initial consultation is free and completely confidential. We can help you determine which path is best for you and protect you against demotion, harassment, and termination.
Our country relies on the reporting of whistleblower nurses, pharmacists, billing coders, and doctors to prevent fraud and corruption in our healthcare system. At Price Armstrong, we protect whistleblowers and safeguard their future. Our Medicare fraud attorneys have extensive experience litigating healthcare qui tam lawsuits and maximizing whistleblower recovery. We know the difficulties whistleblowers face when reporting Medicare fraud, which is why we work tirelessly for our clients.
MEDICARE FRAUD FAQS
The Office of Inspector General for the U.S. Department of Health and Human Services will often investigate reports of Medicare fraud together with the FBI.
Review all billing, summary notices, and explanation of benefits. If you work for a healthcare provider, you may be told by your employer to bill Medicare for services not provided or to change the coding when billing. This is against the law and should be reported.
It is important to have concrete evidence of the fraud before reporting it. While documentary evidence is not required, it is considered in many cases and can play a role in your case. Records of improper charges, emails stating fraudulent charges, or in-office memos can be helpful, however there are important factors to consider before removing company documents. Are qui tam lawyers are experienced in evaluating the evidence of Medicare fraud you have and in navigating the rules about disclosure that ensure your rights are protected.
Simply reporting the fraud is often not enough to receive compensation for whistleblowing. You must formally file a claim in court and include evidence of the misconduct under the False Claims Act.
Under the False Claims Act, the government can choose to take over the case, called “intervention,” or can decline to do so. Less than 15% of cases are intervened in by the government. However, this is often due to factors that are unrelated to the strength of the case, the amount of information brought by the whistleblower, or the nature or extent of the Medicare fraud reported. Some qui tam lawyers will not represent you or pursue your case if the government declines to intervene. But Price Armstrong LLC has successfully represented whistleblowers in non-intervened Medicare cases and has the commitment, resources, and expertise to do so.
CONTACT US FOR A FREE CASE EVALUATION
If you have evidence of past or ongoing Medicare fraud, contact the attorneys at Price Armstrong. We can help you seek justice and protect your rights throughout the process. Call us today at (205) 208-9588 for a free initial consultation and review of your case. Let us fight for you – call now!