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Medicare and TRICARE Fraud
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Healthcare fraud by hospitals, medical offices, pharmacies, ambulance firms, and other sectors in the medical industry is by far the most common type of fraud. It is rampant across the healthcare industry, with up to 10% of all Medicare and Medicaid costs being fraudulent, and this costs taxpayers billions of dollars each year.
False Claims Act lawsuits (and the whistle blowers who initiate them) are the best solution for putting a stop to fraud and holding perpetrators accountable.
What is Healthcare Fraud?
Healthcare fraud happens any time a medical provider defrauds a government healthcare program. There are three primary government programs that scheming providers cheat:
- A federal program that provides healthcare benefits to patients over age 65 and/or with certain disabilities
- A combination federal-state program that provides insurance coverage to low-income patients
- A program managed by the Department of Defense that provides insurance coverage to active duty military and veterans
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There are numerous ways employees at hospitals, pharmacies, nursing homes and other healthcare companies defraud these programs and steal taxpayer dollars. Common forms of fraud include:
- False Documentation
- Changing reports and creating bogus or incomplete medical records to bill government healthcare programs at a higher rate. This is typically done by altering dates and times, exaggerating symptoms and diagnoses, double billing or submitting claims for ineligible patients, among other schemes.
- Billing Schemes
- This can include upcoding (billing for a complex procedure when a minor procedure was performed), unbundling (billing or services that should be performed together separately) or billing for services that were medically unnecessary or never provided at all.
- Pharmacy and Pharmaceutical Fraud
- A pharmacy may commit fraud by billing for a name-brand drug when a generic was used, prescribing medications without doctor oversight, giving gifts to doctors in exchange for referrals, or billing Medicare and Medicaid when the patient never received medication.
- Homecare and Hospice Fraud
- Typical schemes include providing care without proper licensing, falsifying records of medical care and billing for medically unnecessary or services never provided.
- Ambulance & EMS Scams
- This can include providing medically unnecessary transport or "free" rides to patients who are capable of using another form of transportation, entering into illegal deals with hospitals, billing for full-service transportation when only a medical assistance van was used, or falsifying information such as mileage and trip origin.
- Medical Necessity Fraud
- One of the most common forms of fraud, medical necessity fraud, is when a provider misrepresents a patient's symptoms or diagnosis and/or bills Medicare or Medicaid for services that are not medically necessary.
- Anti-Kickback Violations
- When a medical provider or facility that receives Medicare and Medicaid funding gives illegal incentives to other providers in exchange for patient referrals. This fraud is covered by the federal Anti-Kickback Statute and may lead to a criminal prosecution in addition to a False Claims Act prosecution.
- Stark Law Violations
- When a provider refers a Medicare or Medicaid patient to a health care facility where the provider has a financial interest. Although this is not a crime, government investigators may choose to pursue a civil Stark Law action along with a False Claims Act case.
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Who Commits Healthcare Fraud?
Any medical provider or facility that receives Medicare, Medicaid or TRICARE funds from the government can commit healthcare fraud in the whistleblower sense. This includes, for example:
- Nursing homes
- Family practices
- Mental health clinics
- Dentist offices
- Optometrist offices
- Home health care providers
- Hospice care providers
- Ambulance and EMS services
- Pharmaceutical companies
- Medical equipment manufacturers
- Diagnostic laboratories
If you work in the healthcare industry, it's possible that fraud is happening at your workplace. Health care schemes can range from just one or two people to a massive complex fraud that nearly everyone at the company is involved in.
No matter how small or large the fraud is, if you have information about it, the federal False Claims Act gives you a pathway to report it safely and, if done correctly and through a lawyer, "under seal" for initial anonymity.
Health Care Whistleblowers May be Entitled to Monetary Awards & Protection
Under the False Claims Act, whistleblowers can file lawsuits on behalf of the government to put a stop to fraud. Known as qui tam lawsuits, these laws also allow for whistle blowers to receive 15 to 30% of the money recovered by the government in a successful lawsuit.
Health care fraud lawsuits often involve massive amounts of money, which means a whistleblower could potentially receive millions of dollars as a reward for their efforts.
Anyone with knowledge of fraud can report it, including some compliance professionals. However, to receive a whistleblower award, three criteria must be met:
- The qui tam plaintiff must be the first person to report the fraud.
- The information should be non-public and formerly unknown to the government.
- The information must be used by government investigators to build a Medicare, TRICARE, or Medicaid fraud case
Additionally, the False Claims Act protects whistleblowers from workplace retaliation. Under this law, it is illegal for employers to fire, demote or harass employees who report fraud.
False Claims Act lawsuits are also filed "under seal," meaning that the whistleblower's identity is kept secret until the government completes its investigation.
What to Do if Fraud is Happening at Your Workplace
If you have evidence of Medicare, Medicaid or TRICARE fraud at your place of employment (or former job), there are four things you should do:
- 1. Talk to a lawyer.
- Although it may seem easier to report fraud directly to the government on your own, it may destroy your chances of earning an award. A lawyer can tell you what legal procedures you must follow to file a successful report and claim an award. A lawyer can also help you if your employer begins to retaliate against you.
- 2. Preserve evidence.
- Keep detailed records of any fraud you witness and get as much information about it as you can. If possible, preserve copies of documents in a location outside of your workplace.
- 3. Stay quiet.
- Don't tell anyone, including friends and family members, about the information you have. Share it only with your lawyer, and get your lawyer's okay before giving your evidence to anyone.
- 4. Act fast.
- A whistle blower lawsuit must be filed within six years of the date of fraud or within three years once the government becomes aware of it. The first whistleblower to come forward with new and useful information is entitled to the reward. The sooner you report fraud, the better.
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The Medicare Whistleblower 10 Step
Guide to Reporting Healthcare Fraud
& Earning a Reward