Medicaid/Medicare Fraud

About Medicaid/Medicare Fraud

Healthcare providers such as hospitals, physicians, laboratories or nursing homes may be committing Medical Fraud through a variety of billing options. Services are usually billed after the patient has been treated making it easy for less than reputable healthcare providers to make claims under false pretenses. The patient, insurance company and/or government agency such as Medicare, Medicaid or Tricare must trust that the bill is reasonable and correct. There appears to be little accountability. The government is particularly suseptable to medical fraud due to the need to pay an enormous number of claims quickly.

Some of the most common types of Medical Fraud are listed below:

• Billing for services not rendered occurs when a medical practitioner visits a nursing home and bills Medicaid for services provided to more patients than were actually treated.
• Upcoding services is when a medical practitioner bills for a more expensive surgical procedure rather than the routine examination that was actually performed.
• Unbundling Services refers to when a patient receives a battery of tests that should be billed as a "bundled" service but the practitioner bills for the tests separately in order to charge more money.
• Bribing and Kickbacks may be offered to medical practitioners to "encourage" the prescription and purchase of their drugs, products or medical equipment.
• Mislabeling Fraud is when products or services that are not covered by Medicare or Medicaid are mislabeled as products or services that are covered.

Organizations that seek and receive reimbursement for Medicare and Medicaid funds are Government contractors subject to the False Claims Act. This American federal law imposes liability on persons and companies who defraud governmental programs. The law includes a "qui tam" provision that allows people who are not affiliated with the government to file actions on behalf of the government (whistleblowing). Persons filing under the Act stand to receive a portion of any recovered damages.

Healthcare workers and families of nursing home or hospital patients should pay particular attention to the services provided. This will improve the healthcare for patients and loved ones and in some cases ensure Government Healthcare funds are properly spent. Health care organizations will continue to commit Medical Fraud if no one steps up and holds them accountable.

Cases, Settlements, & Verdicts

On February 17, 2011 in the Chicago are,a a doctor, pharmacist and others totaling 14 people in the Health Care industry were charged in connection with federal health care fraud cases. The defendants were each charged with one or more counts of health care fraud, mail fraud, false statements relating to health care matters, and/or conspiracy. Arrest warrants were executed for 10 of the 14 indicted in eight separate, unrelated health care fraud cases worth $225 million.

The Medicare Fraud Strike Force operations has charged 111 defendants nationwide for alleged participation in Medicare fraud schemes. "With this takedown, we have identified and shut down large-scale fraud schemes operating throughout the country. We have safeguarded precious taxpayer dollars. And we have helped to protect our nation's most essential health care programs, Medicare and Medicaid," said Attorney General Holder. "As today's arrest prove, we are waging an aggressive fight against health care fraud."

Helpful Information