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What Is a Qui Tam Medicare Lawsuit?

Understand the importance of a qui tam Medicare lawsuit.

Qui Tam Medicare LawsuitDo you know what constitutes a qui tam Medicare lawsuit? Medicare is a government-funded healthcare plan. It provides eligible citizens with affordable healthcare options. The system relies on honest workers and a reliable healthcare system to make sure it operates smoothly. However, not all healthcare workers play by the rules. And, if they defraud Medicare, they should expect to get caught and pay the price.

The Role of Private Citizens in a Qui Tam Lawsuit

Qui tam comes from a longer Latin phrase meaning, “as the king as well as himself.” This type of lawsuit allows citizens to pursue legal action on behalf of the government. Today, the majority of these lawsuits fall under the False Claims Act. The government passed this legislation to encourage citizens to come forward with information.

The term relator applies to those citizens who bring forth a qui tam lawsuit or whistleblowers. In the world of Medicaid fraud, whistleblowers play an important role in exposing and stopping criminal activity.

Common Types of Medicare Fraud

Those receiving care from a hospital, nursing home, or hospice should pay close attention to what goes on around them. Many reported Medicare fraud cases directly affect patients. Doctors may “over-diagnose” a patient to get a kickback from Medicare. Some healthcare works will even change a patient’s prescription to another drug for unethical reasons.

Patients may notice inconsistencies with their healthcare provider, but few report them. Many of the whistleblowers are actually employees. Here are some of the most common types of Medicare fraud reported:

  • Overcharging for procedures or charging for procedures never administered
  • Partially filling medications but billing for the full dosage
  • Raising prices for Medicare patients
  • Ordering unnecessary tests
  • Changing diagnostic codes
  • Falsifying a patient’s records to justify more costly treatments

Medicare fraud is very dangerous. It can significantly affect the quality of life for patients. This is especially true if the doctor prescribes drugs or treatments that are not medically necessary. Too many patients, however, don’t recognize the warning signs of fraud. Patients trust their doctors and healthcare workers to provide them with honest service. Unfortunately, Medicare fraud is more common than people realize. Some estimates report Medicare fraud affecting between 8% and 10% of claims.

Protections Provided to Relators with the False Claims Act

Speaking up about wrongdoings is the right thing to do, but many people are afraid to come forward. Those committing Medicaid fraud don’t want to get caught. The legal ramifications for cheating the government are very harsh. Guilty parties may find themselves serving time or paying a hefty fine.

When someone blows the whistle on Medicaid fraud, they’re putting themselves at risk. Those running the scheme may try to silence them. However, the False Claims Act helps to protect whistleblowers from retaliation. It makes it illegal to threaten, harass, suspend, or fire a relator. It’s important to note that each state imposes its own statute of limitations.

Money Awarded to Whistleblowers with the False Claims Act

Whistleblowers can expect to receive something in return for their help. Under the False Claims Act, they receive a percentage of the money the government is able to recover. Most of these awards fall between 15-30 percent of the settlement.

Depending on the size of the case, this can be a large amount of money. The total amount is also dependent on whether the government intervened in the case. It’s not uncommon for a whistleblower to receive millions of dollars for their help in cracking a Medicare fraud scheme.

With the risk of retaliation so high, even with protections in place, the monetary award is the only reason some relators speak up. Thanks to whistleblowers, the Department of Justice was able to recover over $2.5 billion in 2018. Without private citizens reporting tips, the majority of fraud cases would still go unnoticed.

The Role of a Lawyer in a Qui Tam Lawsuit

If you have information about possible Medicare fraud, the government wants you to report it to the Office of the Inspector General. While you may want to let everyone know, it’s best to keep it to yourself. You never know who you may upset in the process, and for your safety, you should stay anonymous for as long as possible.

Before reporting your tip, however, be sure to consult with a lawyer who handles whistleblower lawsuits. Your lawyer will do everything possible to protect your identity and make sure you get your full settlement. Never try to represent yourself. Contact the skilled qui tam Medicare attorneys at Bothwell Law Group by calling 770.643.1606 today.

How Common Are False Claims by Medicare Providers?  

False claims by Medicare providers are more common and varied than most people think.

false claims by medicare providersCan you imagine the impact false claims by Medicare providers could have? Medicare is often the difference between a patient being able to receive health care and having to do without. In spite of the good it does for so many, there are those who attempt to game the system. That includes false claims by Medicare providers. How prevalent are these claims? It happens more often than most people realize.

Facts and Figures for Recent Years

Since the advent of the 1863 Federal False Claims Act, whistleblowers have come forth to stop specific incidents of fraud. While the majority of fraud once included fraudulent claims by suppliers and contractors, falsified Medicare claims increased significantly by the 1990s.

According to figures prepared by the US Department of Justice and released through the Department of Public Affairs, lawsuits filed between 1986 and 2018 recovered more than $59 billion. Much of that figure had to do with claims made by providers reported by whistleblowers and subsequently triggered lawsuits.  

During 2018 alone, 767 lawsuits related to provisions in the FCA began moving through the court system. Of that number, whistleblowers initiated 645 lawsuits. This continues the pattern that emerged over the last decade of new FCA cases having to do with alleged cases of false Medicare claims.

How Do They Do It?

There’s more than one way to go about falsifying Medicare claims. Providers who engage in this type of activity are likely to try one or more of the following:

  • Billing for services never performed: This may involve patients who often seek medical care and would not notice receiving one more claim report.
  • Billing for services that were unnecessary: Padding the claim with procedures or services the patient does not need is likely to draw even less attention from the patient.
  • Upcoding: Instead of billing for services rendered, the provider bills for similar services that are more costly and not merited given the patient’s current state of health.
  • Prescribing medications that the patient doesn’t need: The motivation here could be a kickback from a manufacturer in exchange for increasing the demand for a particular drug or classes of drugs.

These are only some of the more common approaches to creating false Medicare claims. Depending on the amount of effort put into creating documentation to back up the claim data, the fraud may be hard to detect even during a medical audit.

Signs Indicating an Altered or Completely False Claim

The fact that a false claim can be difficult to spot does not mean it’s impossible. A few signs could indicate all is not on the level. Knowing those signs makes it easier to determine if someone is the victim of a provider.

You may find that provider statements and receipts don’t match the details on the claim reports issued by Medicare. For example, you receive a claim report for services rendered on a date when you were out of town. That’s a sign something is wrong.

Even if the dates are right, the treatment received is not the treatment listed on the claim report. This can be more difficult for patients to spot if they are not familiar with the name of the treatments. It’s often helpful to compare any statements received from the provider with the detail on the claim report.

Perhaps the date is correct and the description of the treatment matches. What is different is the expense filed with Medicare. It happens to be more than initially quoted.

Any of these scenarios could be honest mistakes. The changes could also be intentional. If you talk with the provider and get a feeling that there’s something other than a clerical error involved, it’s time to take action.

What Can You Do About False Claims by Medicare Providers?

Protect yourself by keeping a log of all your medically-related appointments. That includes trips to the pharmacy to fill prescriptions. This allows you to cross-reference dates, treatments, and even events like annual physicals.

If you believe the activity is not an isolated event and the provider makes no effort to correct the problem, consulting with an attorney is a smart move. The attorney can help you assemble the necessary data and prepare to take legal action, including contacting Medicare and providing information about what you believe is taking place.

Do you suspect that a Medicare claim is fraudulent? Call 770.643.1606 to speak with one of the skilled lawyers at Bothwell Law Group today. If there is evidence of false claims by a Medicare provider, we’ll use every legal means to get to the truth.

What Happens in Medicare Qui Tam Cases?

Learn more about the process for Medicare qui tam cases.

Medicare Qui Tam CasesPrivate individuals use Medicare qui tam cases to show that a person or group has committed fraud against the government. The term “qui tam” is from a Latin phrase. It refers to someone who pursues legal action on behalf of the government as well as themselves. It originated in 13th century England, where it has since fallen into disuse. However, the United States still uses qui tam writs under the False Claims Act and a few other more specific laws. Cases of fraud against the government are the most common types of qui tam cases, especially in Medicare and defense contracting.

Qui Tam Overview

A private individual files a qui tam lawsuit on behalf of the federal government, usually under the False Claims Act. This individual, also known as a relator, is the plaintiff in a qui tam suit. People often refer to these suits informally as “whistleblower” suits. However, this term is overly broad, as the U.S. has other whistleblower laws besides the False Claims Act.

History of Whistleblower Law

The U.S. Congress originally enacted the False Claims Act during the Civil War. This legislation was in response to widespread fraud by government contractors against the Union Army. Congress removed many of the incentives for whistleblowers to come forward in World War II.

Congress restored these incentives in 1986, and the number of qui tam suits has multiplied since then. Lobbyists for the healthcare and defense industries have often attempted to weaken the False Claims Act since 1986. However, these efforts have generally been unsuccessful. The U.S. government has recovered about $40 billion since the 1986 reforms. Whistleblowers have received over $4.2 billion of this total.

Qualifying Acts

The False Claims Act generally covers false claims in federally funded contracts and programs. These programs include Medicare and Medicaid. Specific acts include submitting false claims for payment or causing the submission of those claims. They also include making false statements to get fraudulent claims paid. The concealment of records of fraudulent claims is another violation of the False Claims Act. Additional acts that can result in a qui tam suit include conspiring to defraud the government.

The most common type of false claim is one for products or services the claimant never provided. It also includes payment claims that violate contract, regulations, and statutes. Each false claim may constitute a separate violation of the False Claims Act. This provision means that qui tam suits often charge the defendant with a large number of violations.

The deadline for filing a qui tam suit under the False Claims Act is the greater of the following:

  • Six years after the violation
  • Three years after the government should have known about the violation

In no event can a relator file suit more than 10 years after the violation.

Defendant Liability

The defendant in a qui tam suit is potentially liable for three times the value of damages to the government. The defendant is also subject to civil penalties for each false claim. These can include invoices, demands for payment and other payment documents. These penalties can range from $5,500 to $11,000 for each claim. Many specific documents can form the basis for a qui tam suit, depending on the industry. The forms for Medicare cases include the following:

  • Medicare enrollment forms
  • CMS Form 1500
  • Form UB-92
  • Cost report forms
  • New drug and abbreviated new drug applications
  • Pharmaceutical pricing reports

Pharmaceutical pricing reports include ASP data forms and Medicaid rebate quarterly reports.

Relator Compensation in Medicare Qui Tam Cases

A person must file a qui tam suit to be eligible for compensation under the False Claims Act. It isn’t enough to just inform the government about a false claim. Furthermore, the government must recover money as a result of the suit before the relator can receive compensation.

A relator should receive between 15 and 30 percent of what the government recovers. This range applies whether the case results in a settlement or favorable verdict. The exact amount primarily depends on the significance of the roles that the relator and government play in the case. A more significant contribution by the relator increases the compensation. A more significant contribution from the government decreases the compensation.

The relator’s compensation is generally between 15 and 25 percent of the recovered damages if the government joins the lawsuit. If the government doesn’t intervene, the relator should receive between 25 and 30 percent of the recovery. Each relator gets a portion of the total compensation in qui tam cases involving multiple relators. The individual contribution of the relator determines the portion each individual receives.

If you are aware of fraud, you have protection in Medicare qui tam cases under the False Claims Act. Contact the skilled attorneys at Bothwell Law Group by calling 770.643.1606 today.

How to Protect Yourself as a Medicare Whistleblower

Is it dangerous to be a Medicare whistleblower?

medicare whistleblowerThe benefits of being a Medicare whistleblower are tempting, but do they outweigh the risks? Most people want to do the right thing, but when they are under pressure to provide information, office staff, healthcare providers, doctors and others caught up in fraudulent schemes sometimes say they were afraid to speak out. For others, the lure of securing a major payout is their major motivation. Find out how to make a complaint to enjoy the most protection.

Medicare Fraud Does Not Happen by Accident

The Association of American Physicians and Surgeons recently did a survey of their members on the topic of Medicare fraud. What they found was shocking. Over 80 percent of doctors fear an investigation. The majority weren’t defrauding anyone. They’ve just bought into the idea that complicated billing codes are the root of recent fraud cases — and the sizeable financial ramifications.

Nearly a quarter of practices no longer accept Medicare patients for the same reason. They don’t want to deal with the risks. A look at actual cases involved Medicare fraud show these fears are unnecessary. Medicare fraud doesn’t happen by accident.

Take, for instance, the case of Williston Rescue Squad, Inc., in South Carolina. The ambulance service had a year’s long history of transporting patients by ambulance when it wasn’t necessary and falsifying documents to meet Medicare transfer requirements. Finally, a clinical social worker who worked at a local hospital turned in the business.

Remember, Medicare rarely pays all your medical bills. So as the government was being defrauded, so were the patients!  The company replaced three top executives and agreed to pay the government $800,000. Because the social worker raised the complaint by suing the company in a qui tam lawsuit, she received $160,000 of the settlement. The False Claims Act has revolutionized many industries by motivating change from within organizations. The protections involved are as important as the potential benefits, but they aren’t always what they appear.

Surprisingly, the lawsuit listed the name of the whistleblower and her association with the Williston Rescue. The company, her employer and the general public knew she spoke out. Her name is Sandra McKee. She still lives in Augusta, Georgia, and still works for U.S. Renal Care, Inc.

Protection for Whistleblowers Depend on How You Complain

Whistleblowing does not always guarantee your anonymity, though working with an experienced legal team can help safeguard your privacy. There are many ways to legally protect yourself from the backlash. For instance, federal law prevents:

  • Firing
  • Demoting
  • Harassment
  • Industry blacklisting
  • Unreasonable transfers

A common, new trend is employees getting into trouble for venting their concerns over social media. While these individuals believe they are doing the right thing, this doesn’t constitute “whistleblowing.” By airing grievances in the public eye, you open yourself up to ramifications at work, as well as potential legal problems. Your employer could fire you and sue for defamation. Courts are finding in favor of businesses in these situations. Employees fired for public complaints have also gone without unemployment.

That said, most employers cannot fire you for complaining directly to management. One whistleblower who remained anonymous not only successfully sued her employer for firing her in retaliation for complaints, she went on to sue the government for accepting too small of a settlement. And she won.

False Claims Cases Are Not Get-Rich-Quick Schemes

Consider the case of James Swoben, a former employee of a Medicare Advantage Organization doing business with DaVita Medical Holdings LLC. Swoben alleged the Medical Services Organization instructed their healthcare providers to use the wrong coding information to receive higher rates of reimbursement.

DaVita settled in October for $270 million, of which, Swoben received just over $10 million. However, he first filed the case and saw it dismissed in 2013. An appeal in 2016 revived the case. In addition, one of the original defendants – SCAN Health – settled early on by paying $322 million. Swoben didn’t receive any portion of that payment and had to fight for his right to compensation.

There have been so many qui tam lawsuits raised in the last three years, some courts are raising the stakes for what constitutes fraud. Others are limiting the scope of “retaliation.” One former employee found this out the hard way when she sued based on anti-retaliation protection after she resigned.

Handled differently, the employee could have been a source for positive change while benefiting financially. Finding the right lawyer to walk you through the process makes all the difference.

Click to find out more about Medicare whistleblower protection by contacting Bothwell Law Group online.

Why Medicare Billing Fraud Cases Are Running Rampant and What You Can Do About It

medicare billing fraud

Are Medicare billing fraud cases getting worse? Here’s what you need to know.

Medicare billing fraud cases cost the government $60 billion a year, and the problem continues to grow. Abuse is rampant despite more restrictions on healthcare for seniors than ever before. As more doctors hear about fraud convictions and million-dollar fines, more providers are refusing to provide services to patients on Medicare. Some even refuse referrals. This is just one way Medicare fraud impacts people in real ways and why we need to put a stop to it.

Why Medicare Billing Fraud Cases Are So Common

There are several reasons billing fraud is on the rise. Some doctors say it’s easy to make billing errors given the complicated medical coding currently in use. Most fraud is really an accident. It seems like a reasonable explanation. Unfortunately, it doesn’t really address the most common fraudulent charges cropping up in today’s investigations.

There are clinics, care facilities, home-based healthcare workers, and others that aren’t just charging people for the wrong services. They’re charging for services never rendered for patients they haven’t seen. They’re splitting visits up and claiming each step in treatment occurred on a different day. That gives the office the ability to add additional office or exam fees. In some cases, doctors are charging patients who simply don’t exist.

Treatments Can Trigger Investigations

Unfortunately, it’s impacting what legitimate healthcare providers are doing. According to the Association of American Physicians and Surgeons, 71 percent of doctors restricted the services they offer. That’s because they’re afraid of triggering investigations. Another 23 percent won’t take on new Medicare patients at all.

Many times, it’s not the doctors or the facilities who are perpetrating the fraud. The latest wave of Medicaid billing deceptions come by way of shady medical supply companies who steal doctor’s licensing information and use it to forge subscriptions for expensive medical devices.

Hospice Isn’t Safe, Either

Another hotbed of fraudulent billing activity occurs in the growing hospice industry. Payments made for end-of-life care increased by 81 percent over the last decade. In 2016, it accounted for $16.7 billion of Medicare payouts. Officials estimate 10 percent of those payments were illegal disbursements. Scam artists have made a new industry of Medicare fraud, starting with the patients and families who are the most vulnerable.

The National Hospice and Palliative Care Organization blames extraordinary hurdles in coding for the fact so many hospice organizations are mistakenly bilking the system. The most common issue? Centers charging patients for “general inpatient care” when they receive their services in their homes. The difference is not only obvious, but it results in a reimbursement difference of over $500 per day.

It’s heartbreaking to know that even with rampant billing fraud within the Hospice community, patients overwhelming receive substandard care. A review by the Inspector General at the Department of Health and Human Services (HHS) found 85 percent of patients were not receiving the level of medical care determined necessary by their treatment plans.

The reason Medicare fraud is growing is simply that the system makes it so easy. Patients don’t see their bills before they before the insurance company pays for services. Confusing medical billing impacts whether they’re able to assess what the statements mean once they arrive. And for those in inpatient programs, reporting Medicare fraud can come at an exceedingly high price.

Putting a Stop to Medicare Fraud

Who can help stop medical billing fraud?

  • Patients
  • Family members
  • Healthcare workers
  • Office staff

Patients and their family members need to be diligent when reviewing Medicare statements in order to detect any errors. When discovered, contact the healthcare provider and ask for a correction. If you’re treated poorly or given the run-around, it might be time to take extra steps to protect your loved one’s benefits.

Healthcare workers and office staff can also help prevent fraud from hurting their patients. Remember, some services have limited coverage. If someone is incorrectly billed for a service or a piece of medical equipment, they won’t receive that coverage again. Speaking up preserves your ability to give patients the care they need and preserves your ability to earn an income.

How Qui Tam Lawsuits Stop Fraud and Boost Your Bank Account

Under U.S. law, any person can sue a business or individual who is defrauding the government. You represent the nation and share a portion of the reward or settlement. Whistleblowers calling out Medicare fraud received millions of dollars, and they’ve helped stop companies from preying on the sick and elderly.

There’s a certain way you have to make the complaint in order to be eligible to receive any funds, so make sure you take your concerns to a lawyer who is familiar with Medicare fraud litigation.

Contact the skilled Medicare billing fraud attorneys at Bothwell Law Group by clicking or calling 770.643.1606 today.

What Do Medicare Fraud Attorneys Do with False Claims Reports?

Could you put a stop to bad billing and possibly have a chance to receive big rewards with help from Medicare fraud attorneys?  

Medicare Fraud AttorneysMedicare fraud attorneys help people fight back against health care providers and clinics that use and abuse the elderly. Bad billing practices don’t just put more money into a clinic’s pocket. They make it harder for people to get the medical coverage they need.

Are you a victim of Medicare fraud? A lawyer can help you to make a difference, potentially improving the quality of health care for people in your community. In some cases, you may even be able to collect a partial settlement for your role in stopping crime.

Why People Should Care about Government Related Fraud

Sometimes, it’s tough to take the idea of government fraud seriously. We’ve all heard the reports of the outrageous way the Pentagon, among other departments, spends absurd amounts of money. Let’s take a few moments to explain those $600 toilet seats.

Granted, there are times when government funding is gravely misused. Other times, the media twists what they know to create a sensational story. Journalists might also get the wrong idea if they don’t know how to interpret the data on which they are reporting. This happened in the 1980s when news coverage based on a Pentagon invoice hit the papers.  

What the reporter didn’t understand – or perhaps, didn’t care to mention – is the invoice was for a bulk order. The cost wasn’t assigned per item but for the lot. The result was a list of items, including a toilet seat and a jet engine, each unit priced at $600.

While certain members of the government are an exception, the pervasive overspending you might believe happens in government spending across the board doesn’t exist. Departments stretch their budgets to the limit and sometimes go without to create balance. This is especially true for health care programs like Medicaid and Medicare. When someone steals from their coffers, other individuals go without the necessary care.

Suing a Fraudulent Medicare Provider

Whistleblower laws give people just like you the chance to make a difference and reap the benefits. When you turn in false Medicare claims to a law firm, they can file a case against the business on behalf of you and the U.S. government.

Over the years, the government has used this law to clean up several industries and to clear big problems out of our workforce. From safety regulations to insider trading and now insurance fraud, whistleblowers laws improve quality of life for Americans across the board. Not only can you benefit from the decisions and the waves they make throughout the healthcare industry, but you can also collect a portion of the fines and other fees imposed on bad businesses.

This incentive has existed since the 1800s when Lincoln was desperate to find a way to stop government fraud related to war efforts. Troops were starving and freezing to death because of companies falling short on their promises. The law has changed over the years significantly. Congress has reigned in whistleblower protection and compensation for the benefit of big business, and they’ve done the opposite.

The Healthcare Industry

Today, the majority of lawsuits focus on the healthcare industry. That’s how widespread the problem is, and it hasn’t just resulted in people going without care. In some cases, providers have abused patients to justify their practices.

Under the False Claims Act (FCA), an individual can receive 15 to 30 percent of a settlement, which often goes into the millions. An attorney will explain the way the law applies today and how suing a fraudulent medical office can benefit you and your family financially.

According to the The National Whistleblower Legal Defense & Education Fund, whistleblowers filed 92 percent of the successful Medicare fraud cases in 2017, amounting to $3.4 billion dollars in funds collected by the government. The government paid $392 million to those who brought the fraud to light.

The Impact of Fraudulent FCA Filings

Unfortunately, there have been people who file maliciously against providers too, not because they think they’re breaking the law but because they’re hoping for a payoff. The result has been a breakdown in the effectiveness of FCA protection and prompting a call by the U.S. Department of Justice for Congress to enact new laws to control Medicare fraud and keep whistleblower suits out of court.

It’s essential to work with a law firm that invests time in researching and assessing your FCA case before filing. During billing, mistakes sometimes happen. Your provider might not be guilty of fraud so much as human error, and in certain situations, filing as a wronged patient makes more sense than filing as a whistleblower.

Click to find out more about Medicare fraud attorneys by contacting Bothwell Law Group online.

How Do Fraudulent Insurance Claims Affect Medicare?

Fraudulent insurance claims rob needy people of adequate healthcare.

Fraudulent Insurance ClaimsFraudulent insurance claims come in all varieties, and ultimately, it is the people who need the most who suffer more than anyone else. Substandard providers make money off the poor while delivering shoddy services. When a problem is widespread enough, policies change to limit services to keep unscrupulous medical providers from taking advantage of them. You can help preserve services and employment opportunities for those who are above-board by reporting fraudulent billing practices.

Common Types of Fraudulent Claims

It’s not always easy for a patient to identify fraudulent Medicaid billing. Providers can change someone’s address, for instance, so bills go to the wrong address. They can also be confusing for laymen to understand. However, it might help to know the main ways health providers defraud the Medicaid system.

The most common types of insurance fraud include:

  • Billing for the wrong services
  • Billing for services never provided
  • Changing the date of services rendered
  • Providing and billing for unnecessary services
  • Naming the wrong patient

Let’s go through each type of fraud and explain how it might show up on your medical bill. If you notice problems, be sure to get in touch with a lawyer who has experience in whistleblower laws. If the court finds the provider guilty, you might be able to collect a partial settlement.

Billing for the Wrong Services or Those Never Provided

Different types of medical care receive reimbursement at different rates. For instance, if you go in for a typical dental cleaning, your bill should say “Prophylaxis” instead of “Periodontal Scaling and Root-Planing.” The latter is a more labor-intensive service, so it justifies a higher payment from insurance plans.

Insurance companies know some medial practices bill incorrectly, which is why they put measures in place to justify upgraded services. For example, they might require additional x-rays or an in-depth assessment of periodontal disease before signing off on a scaling and root-planing service fee. If you’re seeing several additional services on your bill you don’t remember experiencing during your visit, there’s a good chance your bill is inaccurate.  

Some patients might shrug this off in the moment, but your insurance might only cover one of these services a year. So they won’t cover the charge if the care becomes necessary later in the year.

Changing the Date of Appointments on Medical Bills

Changing dates on medical billing is one of the latest methods dishonest doctors are using to boost their profits. They split up billing for a single visit between several different days. If you went to the doctor over a persistent cold and received an allergy test, you might get two separate bills with two different dates on them. By splitting up the services, your doctor’s office can charge the insurance provider double for office visits and associated fees.

Providing Unnecessary Services to Justify Additional Charges

Providing unnecessary services is one of the most dangerous types of insurance fraud in existence today. Instead of lying about the level of care they provided, some practitioners protect themselves against fraudulent billing claims by delivering unnecessary treatments. This seemingly ensures an airtight paper trail regardless of the type of investigation performed. Unfortunately, providers who take part in this scheme build up a tolerance to their actions over time until office staff reports the activities.

Any practice dependent on Medicaid needs to be under scrutiny to prevent these types of patient abuses from occurring. Dentists will cap every tooth in a child’s mouth or push a patient to undergo a preventive knee replacement surgery in order to bill for high-dollar services.

The problem doesn’t stop at the unnecessary risks patients undergo, or the lasting impact invasive procedures have on their quality of life. When this type of fraud is persistent, the insurance provider raises the standards of proof necessary for essential procedures. People who genuinely need them have a hard time getting them covered by insurance — if they can get them at all.  

Second opinions exist for a reason. Be sure to get one before your doctor or other health care provider convinces you to undergo an expensive procedure.

Billing the Wrong Patient

It may seem like it’s in the spirit of Robin Hood to use one patient’s access to affordable health care to provide care for someone going without the necessary care. The problem is the doctors who make these kinds of deals are often taking some sort of payment and funneling it straight to their bank accounts. Additionally, problems arise when the person whose insurance is utilized needs services of their own. Due to limits and restrictions on covered care, the real insured patient might have to pay out-of-pocket.

The coding involved in medical billing is complicated and mistakes will happen from time to time. However, when doctors or staff deal with records incorrectly on purpose, they put people at risk. Help us fight back.

Contact the skilled fraudulent insurance claims attorneys at Bothwell Law Group online or by calling 770.643.1606 today.

Why Kickbacks Are So Common in Medical Insurance Fraud

Medical insurance fraud commonly comes in the form of kickbacks.

medical insurance fraudHealth services make up a large portion of the American economy, so medical insurance fraud is a common occurrence. Kickbacks are one of the most common forms of illegal behavior in the healthcare setting, but why is this the case? And what are kickbacks, anyway? Read on to find out.

What Are Kickbacks and How Do They Work?

A kickback is similar to a bribe in that one party will pay another party for improper benefits. Looking at an example is the best way to understand what a kickback is.

In a hypothetical healthcare setting, let’s say you have the patient, the patient’s primary care physician, the patient’s insurance company and a doctor who focuses on treating arthritis (we’ll call this doctor “John”). Now let’s assume the patient suffers from joint pain and goes to see his primary care physician. After an examination, the primary care physician believes the patient might have arthritis and refers the patient to Doctor John. The patient sees Doctor John and receives medical treatment. Along the way, the patient’s insurance company pays each doctor for the medical services they provide.

In a hypothetical involving a kickback, the patient’s primary care physician examines the patient. But instead of referring the patient to Doctor John, refers him to Doctor Bob. In return for referring the patient to Doctor Bob, the primary care physician receives a payment from Doctor Bob as a “reward” for sending him a new patient. In this example, the payment Doctor Bob sends to the primary care physician is a kickback.

Why Are Kickbacks Common?

One reason why kickbacks are so easy is that they’re easy to hide. Looking back at the above example, Doctor Bob and the primary care physician could be great friends who spend a lot of time together, perhaps playing golf once a month. During each of these golf games, Doctor Bob puts a roll of unmarked $20 bills in the primary care physician’s golf bag when no one is looking.

Unless the physician tells someone about this kickback, there will be almost no way to identify or trace those unmarked bills. Do you think the primary care physician is going to record the cash in the office business ledger or report it to the IRS as taxable income? The answer is no. An individual can easily hide a few hundred dollars per month of ill-gotten gains by simply using the cash for ordinary purchases. In fact, the primary care physician’s spouse probably won’t even know about it.

But one of the biggest reasons why kickbacks are so common is the nature of the healthcare system in the United States. Before a patient can see a doctor who focuses on a particular area of medicine, they need a referral. In other words, if a patient wants to see Doctor B, they must first see Doctor A.  That doctor will give them a referral to see Doctor B.

In a perfect world, Doctor A will always refer patients to the best doctor, whether it’s Doctor B, C or D. Who Doctor A ultimately chooses is a judgment call. Doctors may not be able to provide a plausible reason to explain why they choose to refer a patient to one doctor and not another. This means it’s very easy to set up a situation for kickbacks.

Kickback Coverups

The only difficult part is covering up the kickback itself. As long as the kickback is small, it can probably remain hidden. But healthcare in the United States is expensive. With so much money flowing in and out of hospitals, doctor’s offices and clinics, it’s hard to keep track of it all. On top of that, the medical and financial records created from just one doctor’s visit are immense. Anyone would have trouble sorting through to catch a kickback scheme in action.

This is especially true in cases where a person has numerous medical procedures and bills or is in under medical care for a long period of time. Think of a person who undergoes cancer treatment, then spends several months in hospice before their death. That could be a good example of a case where unscrupulous providers could bill much more than they actually should.

In many situations, only an individual with a very detailed understanding of the financial operations of a healthcare facility can identify a kickback scheme. This is why whistleblowers are so important to stop kickbacks.

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The Most Common Types of Medicare Fraud, and How to Know It When You See It

Medicare fraud occurs often, but here is how you can sometimes spot it.

medicare fraudMedicare is a gigantic government program, so it’s no wonder that Medicare fraud exists. But what exactly is Medicare? It is a government-run health insurance program that uses private insurance companies to help administer payments for the healthcare services of millions of individuals. Medicare is typically for those 65 years of age and older, as well as younger individuals who may have a recognized disability.

With so many rules, regulations and people involved in providing Medicare, it’s not surprising that some find ways to cheat the system and steal money from the United States government, medical centers and patients. The following list describes some of the more common ways this cheating goes on and how to potentially spot it. By knowing how to spot it, you might be able to put a stop to it and even earn some money as a whistleblower.

Fake Billing

Fake billing occurs when an insurance company receives a bill for medical care a patient did not receive. Perhaps a patient got an X-ray for a possible broken bone. However, the X-ray revealed there was no broken bone, so the patient goes home with some ibuprofen. But the medical center sends a bill to the Medicare insurance company for not just the X-ray and the ibuprofen, but a cast as well, even though the patient didn’t receive a cast.

You can sometimes detect this type of Medicare fraud by carefully examining a patient’s medical bill. The patient will be the best individual for knowing what medical care they received. However, this isn’t always easy. The patient may not remember or even care, frankly, because they’re not paying the bill. In that case, it will be up to the United States government or the insurance company to spot it. But the only way they can figure out if fake billing took place is to compare the bill with other medical records, which is not an easy task.

Unnecessary Medical Procedures

Unlike fake billing, where there is a bill for a medical service the patient never received when there is an unnecessary medical procedure, the patient actually receives the medical care that the Medicare insurance company receives a bill for. This makes detection very difficult because even the patient won’t know there is a medical bill mistake. When a patient has a medical problem, they don’t know what’s going on or how to fix it. So how does a patient know if a particular medical procedure is not necessary?

Think about an instance when you might have excessive coughing, wheezing, and shortness of breath. Your doctor says you might have pneumonia and orders you to get a chest X-ray. You get the X-ray and it turns out you only have bronchitis. Was the chest X-ray necessary? How do you know? Maybe your doctor knew it was an unnecessary test and was trying to overbill your Medicare insurance provider. Or maybe your doctor was just trying to play it safe. Either way, if you don’t know, it’s unlikely the United States government will ever know.


Upcoding refers to the practice of billing the insurance company for a more expensive medical service than the patient actually received. In most instances, the higher medical bill will be for something related to the medical care the patient did receive. For example, a patient might go into the emergency room for fainting spells. The emergency room doctor diagnoses the patient with anemia. After providing a blood transfusion consisting of two pints, the hospital discharges the patient.

However, when the hospital bills the insurance company, the hospital will say that the patient had a lower red blood cell count than they really did. They might claim the patient received a blood transfusion consisting of three pints instead of two. As a result, the hospital can charge the insurance company more money.

Upcoding is common for at least two reasons. First, it’s tough to detect. The patient in the above example may not remember if they received one, two or three pints of blood during the transfusion. Additionally, when looking back at the treatment records, the doctors and nurses may not remember either.

Second, using special codes makes it easier to commit “service unbundling,” which refers to billing using individual codes for specific services instead of using a single code for a cheaper, packaged medical service. Not everyone will be familiar with these codes and most of the time, it’s a computer that reads the codes and processes the bills. The best way to spot it is to look for medical treatments that the patient never received.

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What Happens During Medicare Kickback Lawsuits?

medicare kickback lawsuits

Medicare kickback lawsuits occur fairly often when litigating the False Claims Act

medicare kickback lawsuitsThe False Claims Act is a law designed to fight fraud. One of the biggest areas of fraud against the federal government is in the healthcare industry. Specifically, Medicare is a popular area for fraudsters. They work hard to steal government money with the kickback being one of their tools of choice. But before we can answer the question of what happens during Medicare kickback lawsuits, we need to understand what a kickback is.

What Are Medicare Kickback Lawsuits?

A kickback is a little bit like a bribe, where someone receives a payment in return for sending business to another person or company. Let’s look at an example to explain a kickback.

Imagine a doctor’s office that treats patients who receive Medicare benefits (Medicare is a federally-run health insurance program for older Americans). The doctor’s office may treat the patients, but the federal government actually pays the bulk of the medical fees the patients incur at the doctor’s office. This doctor’s office can be a part of a kickback plan in several potential ways.

First, the doctor’s office could pay people to serve as fake patients. With a fake patient, the doctor’s office can then bill the federal government for medical services that no one ever received. In return for having a person pretending to be a patient, the doctor’s office can pay the fake patient a cut or commission (this is the kickback) of what the doctor’s office received from the federal government.

Second, the doctor’s office has a special agreement with another healthcare provider, such as a hospital. This hospital will refer patients to the doctor’s office for additional medical care they do not need. In return for this extra business and the opportunity to further bill the government under Medicare, the doctor’s office will make a payment, or kickback, to the hospital.

Unless the federal government audits or investigates all the medical providers in the country, it will be impossible for the government to learn of every instance of Medicare fraud. And as you might imagine, the government doesn’t investigate every single medical care provider. Therefore, it must rely on whistleblowers to bring this fraud to its attention. The existence of this whistleblower helps shape what happens during a Medicare kickback lawsuit.

What Will Happen in a Medicare Kickback Lawsuit?

The first thing that will usually happen is a whistleblower reporting the fraud to the appropriate government authorities. One way to do this is by reporting the fraud directly to the federal government. For individuals wishing to take advantage of the False Claims Act’s qui tam provision, they will notify the federal government only after filing the appropriate qui tam complaint in federal court in secret. Besides the court, the only other party who will know about the qui tam lawsuit will be the government. This secrecy will only last until the federal government completes its investigation.

After the federal government receives notice of the qui tam lawsuit, it will investigate the alleged fraud. The government has 60 days to conduct its investigation, but that’s rarely enough time. So the government usually gets extensions to continue its research. Once the investigation is complete, the federal government will make a decision. Here, they’ll decide whether or not it should take over the qui tam lawsuit from the whistleblower (now called a relator) or allow the relator to continue the qui tam lawsuit themselves.

The Government’s Response

Because of the massive amount of resources of the federal government, it’s a good sign if they want to take over the lawsuit from the relator. If the government declines to take on the case, it’s usually a bad sign for the relator. Declining the case usually means either the government doesn’t have a strong case. Or it could mean there is not much hope of recovering a large amount of money. Because of this, a person or organization alleged of fraud under the False Claims Act will feel hopeful that they can win the case if they see the federal government decline to become a part of the lawsuit. They might fight harder in court and make the relator’s legal case more difficult to win.

In part three of the Medicare kickback litigation process, the trial takes place. During the trial, the individual or organization charged with Medicare fraud tries to defend itself in court. If the federal government or relator wins its case, then the relator will receive its share of the recovered money. This usually ranges anywhere from 15 to 30 percent. It depends on how helpful the relator was and if they had any involvement in the fraud. Most relators can expect around 25 percent of the money the federal government recovers from the person or organization committing the fraud.

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The Four Most Commonly Prosecuted Types of Medicare Whistleblower Cases

There are many types of Medicare whistleblower cases where fraud can potentially exist.

Medicare whistleblower casesLooking for more information about Medicare whistleblower cases? Medicare is a special government program where Americans aged 65 years and older receive health insurance benefits that the federal government pays for. The government uses insurance companies to help administer and process these benefits and pays for Medicare with taxpayer dollars.

With the aging baby boomer population, millions of individuals are using Medicare benefits. With such widespread use comes the opportunity for fraud. However, some forms of fraud occur more often than others. We’ll discuss some of these more common types of fraud that often lead to a whistleblower lawsuit and qui tam action.

Accepting or Offering Kickbacks

Kickbacks occur when someone offers or accepts money for improperly diverting or creating business that wouldn’t otherwise exist. For example, a clinic that pays a primary care physician $100 for each Medicare-eligible patient the doctor sends to the clinic could be an example of a kickback. The clinic offers the kickback of $100 and the primary care physician accepts the kickback.

In some situations, kickbacks can be more harmful than just stealing money from the federal government. If a doctor orders a medical procedure the patient does not need because it will give the doctor a kickback from the hospital or clinic providing the procedure, it can put the patient’s health at risk.

Billing the Federal Government for Nonexistent Services

False billing is another common form of Medicare fraud. Basically, the doctor or medical provider will bill the federal government for a medical service that never takes place. An example might include sending a bill for Medicare reimbursement for doctor’s visit that never happened. Or it could include a piece of medical equipment the patient doesn’t use. Instead, the doctor keeps the medical equipment and sells it under the table for cash.

Unless the Medicare reviewer is at the doctor’s office to see that the medical equipment actually goes into use or witnesses the doctor examine ten patients on a particular day instead of eight (yet bills for 10), it can be tough to detect this type of fraud. It is a very profitable way for unsavory doctors and healthcare providers to line their pockets with cash.

Billing the Federal Government for Medical Services Not Needed

Billing the federal government for unnecessary medical care is a very popular tool for fraudsters. This is because it is very difficult for the government to detect. Why is this so? Think of it this way. How is a Medicare examiner sitting in an office in Washington, DC supposed to know if that MRI or x-ray was not medically necessary? All the official will have are copies of the patient’s medical records, such as written notes from the doctor. If the doctor is taking part in the fraud, the doctor will write anything to support the medical test or procedure that’s not really necessary.

For instance, the doctor may write into a medical record that the patient might suffer from a torn ligament and the MRI is necessary to confirm this suspicion. The MRI will provide the information needed to surgically repair the ligament if there really is a tear. What makes this type of fraud even harder to detect is that the patient may not even know the medical test or procedure isn’t necessary.

All the patient knows is that they went into the office for knee pain and the doctor tells them that they will receive an MRI to see what’s going on in the knee. Even if the doctor knows there is no ligament tear and there is no need for an MRI, there is usually no way for the patient to know this. If the patient doesn’t know, it’s unlikely that the Medicare examiner in Washington DC will know.

Prescription Medication Fraud

Prescription medication fraud can exist in many different ways. Examples include a doctor prescribing a medication that is unnecessary or for a higher than needed dosage. Furthermore, it could include a patient selling his or her prescription to someone else. A final example would be forging a doctor’s signature to get a certain medication.

The most common types of drugs subject to prescription medical fraud are painkillers, like opioids and opiates. So many people are addicted to these painkillers. Therefore, there is a massive financial incentive for patients and doctors to commit prescription medication fraud. This type of Medicare fraud is therefore partially responsible for the painkiller addiction epidemic currently ravaging the United States.

This type of fraud can be difficult to detect. That’s because the doctor or healthcare provider may not be in on it. With a single patient committing the fraud, it is probably less likely that there will be a whistleblower who can identify the fraud and report it to the federal government. Also, if a single patient is committing the fraud, there is usually less money at stake, so any reward by bringing a qui tam action will be relatively small. This means it’s unlikely someone will step up as a whistleblower and relator.

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What You Need to Know about the False Claims Act for Medicare

False Claims Act for Medicare is a significant source of fraudulent activity against the government.

False Claims Act for MedicareIndividuals looking to defraud the federal government often find themselves dealing with the False Claims Act for Medicare. But how is a major government social welfare program connected to a federal law aimed at stopping fraud? We’ll explain how and what it could mean for those on Medicare and taxpayers in general.

What Is Medicare?

Medicare is a medical insurance program run by the federal government. It provides health insurance benefits mostly to individuals over the age of 65. However, individuals younger than 65 can sometimes receive benefits. Medicare is important because unlike private health insurance, individuals receive guaranteed benefits at a very low cost. It is the government, through taxes, that foots the majority of the bill. It’s the government that pays for the bulk of medical services and products. Therefore, Medicare is a prime target for fraud, especially kickbacks.

What Are Kickbacks and How Do They Work with Medicare?

Kickbacks refer to a type of commission or payment that one party pays to another to obtain business or other benefits. Let’s use an example to explain how kickbacks work.

Let’s say you have a clinic that treats older patients, often those who receive Medicare benefits. This clinic treats the patients. Then they file a Medicare claim and receives payments from the federal government for the medical services provided. This is a pretty good arrangement for the clinic. However, it wants to make more money, so it devises a kickback scheme.

Under the clinic’s plan, it recruits Medicare-eligible individuals to serve as fake patients. These fake patients will go to the office and claim they need medical care, even if they really don’t. The clinic then bills the federal government through the Medicare program for non-existent treatment. Not knowing what’s really going on, the federal government sends the clinic Medicare payments. Those payments result in fraudulent gains for the clinic. In return, the fake patients receive a cut of the fraudulent Medicare payments. The cut (or commission) received by the fake patients is the kickback. Here, the clinic has “kicked back” some of its ill-gotten gains to the fake patients.

Another Example

A more common example of kickbacks doesn’t involve any fake patients. Instead of a clinic and a fake patient, let’s pretend we have a clinic and a doctor’s office. Medicare-eligible patients go to their doctor. The clinic and doctor have a special arrangement where the doctor will always send the unsuspecting patients to the clinic for medical care. That’s even if the patient doesn’t need it or the doctor could send the patient to a different clinic or hospital instead. In return for this “guaranteed business,” the clinic gives a cut of its profits from the referred patient back to the doctor. Basically, the clinic pays the doctor to give it patients so the clinic can then bill the federal government and receive reimbursement through Medicare. In this second example, the payment the doctor receives is the kickback.

How Does This Affect You?

For any taxpayer, Medicare fraud means wasted government money. From a big picture perspective, the vast majority of tax revenue collected by the federal government goes to two places. They are the military and social welfare programs, such as Social Security, Medicaid, and Medicare.

With so much taxpayer money paying for Medicare benefits, whenever Medicare fraud takes place, it means taxpayers paid for fraudulent medical services. Ultimately, this means the taxpayer paid taxes it didn’t really need to.

Two Problems Here

For those on Medicare, fraud is a problem for two reasons. First, it jeopardizes the future of Medicare because too much waste from fraud might mean a cut in Medicare benefits. More importantly, it also means Medicare patients may not receive the medical services they actually need.

In the second example from above, there’s a good chance that patients sent to the clinic are not receiving the proper medical care they need. Some patients might be better off going to a hospital. But instead, their doctor sends them to the clinic. In some cases, this could lead to physical harm to the patient. For example, the patient might need a specific procedure or test that can only take place at a hospital, but the doctor sends them to the clinic anyway. As a result, a disease goes undiagnosed. By the time the patient finds out what’s really going on it’s, too late. Or the patient doesn’t need any further testing or medical care but is still sent to the clinic anyway. This could subject the patient to a medical procedure that causes harm.

While these more extreme examples are less likely and most patients involved in a Medicare fraud scheme probably don’t get hurt, the possibility is there. And at the very least, there is a tremendous amount of wasted taxpayer dollars, which is never a good thing. Luckily we have laws such as the False Claims Act. It punishes fraudsters and provides rewards to individuals to investigate fraudulent activity. This helps the federal government recovery lost money due to fraud.

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