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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.

Looking to Find out More about Medicare Kickback Lawsuits?

Contact the skilled Medicare kickback lawsuit attorneys at Bothwell Law Group by calling 770.643.1606 today.

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.

Have Information About Medicare Whistleblower Cases?

Contact the skilled Medicare whistleblower case attorneys at Bothwell Law Group by calling 770.643.1606 today.

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.

Want to Learn More About Medicare and the False Claims Act?

Contact our team of skilled False Claims Act for Medicare attorneys at Bothwell Law Group by calling 770.643.1606 today.

Does the Whistleblower Law Apply to Unnecessary Medical Billings Issues?

Unnecessary medical billings is one of the biggest opportunities for individuals to defraud the government.

Unnecessary medical BillingsGiven the size of the healthcare economy in the United States, it’s not surprising that unnecessary medical billings serve as a potential area for individuals to defraud the government under the False Claims Act. But one of the key parts of the False Claims Act is the qui tam or whistleblower provision. It allows whistleblowers to receive a reward or bounty for helping recover money for the federal government. It is this qui tam provision that helps combat fraudulent activity in the healthcare setting.

Qui Tam Provision

The qui tam provision is also known as the whistleblower provision of the False Claims Act. It provides a reward for individuals who help the government recover stolen money. The reward can range anywhere from 10% to 30% of the amount recovered. This percentage of recovery will vary based on several factors. These factors can include how much assistance the whistleblower provides in prosecution of the fraud, whether the whistleblower did anything illegal themselves to defraud the government and whether the government prosecutes the violator itself or relies on the whistleblower. In most cases, the relator can expect to receive anywhere between 15% and 25%.

As a general rule, the more work the whistleblower has to do to recover the stolen money, the higher reward percentage the whistleblower can expect. Actually participating in the fraud can lower the total amount the whistleblower recovers. However, it will rarely completely eliminate the reward. This is because the federal government knows that sometimes it has to pay a little money to a guilty party so that it may recover a lot of money from other guilty parties.

When Does the Whistleblower Provision Apply?

The False Claims Act covers situations where an individual or company defrauds the federal government for goods or services. Because of the high cost of healthcare in the United States, a lot of government money goes to helping individuals pay for healthcare services. Much of that money funnels through government-sponsored social welfare programs. This creates a wealth of opportunity for insurance companies, hospitals and other healthcare providers to defraud the government. Therefore, problems with medical billing will often come into play when dealing with the whistleblower provisions of the False Claims Act.

Medical Billing under the False Claims Act

Much of the expense of healthcare in the United States revolves around medical services. This can include physical exams, surgeries, medical analysis and testing. Another major healthcare expense deals with paying for medications. Both medications and professional services show up on medical bills. And when someone from the healthcare industry tries to defraud the federal government, evidence will almost always appear in the medical bills themselves.

For example, let’s say the violator is overcharging for a procedure. The higher price charged will appear on a medical bill. If the violator is mischarging the federal government, then the medication or procedure the government paid for but no one received will appear on a medical bill. The unnecessary medical billings will serve as evidence of fraudulent activity.

Therefore, it should come as no surprise that whistleblowers will commonly identify potential fraud in medical bills, as well as use those bills as proof that fraud exists. Often, when an individual wants to serve as a whistleblower, they must provide proof of fraud to the federal government. Documents, including medical bills, serve as persuasive evidence concerning fraudulent activity against the federal government.

Not only do the medical bills support the fact that fraud exists, but they can help calculate the cost of the fraud. Medical bills will show how much money the violator charged the government. The government can then compare this amount to how much the charge should have been. This amount can sometimes exist on another medical bill.

Assessing Medical Fraud Damage

With these two numbers, the government can identify the fraud and calculate how much money they improperly paid. There’s also the ability to identify how often fraud took place. This is important because each instance of fraud is subject to a penalty that ranges from between roughly $5,500 and $11,000.

Finally, all this documentation matters for whistleblowers because it can help calculate how much their reward under the qui tam provision will be. Remember, a whistleblower can receive up to 30% of the total amount the government can recover from the violator. Without knowing how much fraud took place, the whistleblower can’t accurately determine how much the government should recover. From the typical whistleblower’s point of view, the reward is the single biggest reason for blowing the whistle.

Have You Found Potential Fraud in Medical Bills?

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4 Facts Physicians Should Know about the Medicare False Claims Act

Medicare False Claims Act

Medicare False Claims ActAs a physician who files claims through Medicare, there is pertinent information you need to know about the Medicare False Claims act. The False Claims Act allows for the prosecution of individuals who commit fraud against the United States government. Most physicians believe they are not at risk for committing Medicare fraud. However, it is crucial to understand the act in order to protect yourself from liability.

Are you a physician who files claims to Medicare for services you provide? There are 4 facts you should know about the Medicare False Claims Act:

#1. It is always illegal to misrepresent a service or product supplied to a patient in a Medicare claim.

In some cases, physicians believe they are acting out of benevolence, falsely diagnosing patients to allow them access to further coverage under Medicare. Whether or not the intention was to commit fraudulent activity in order to obtain government funds, it is never acceptable to misrepresent a service or product supplied in a Medicare claim.

#2. You may be liable for your employees’ actions.

If someone in your billing department or another employer bills for a service or product that wasn’t provided or upcodes a service, you may be liable for their actions. This is because you are the person receiving the fraudulently obtained government funds. Also, it is your responsibility to supervise the employees you hire.

#3. Accepting gifts or kickbacks of any kind is prosecutable under the False Claims Act.

If a vendor of any kind offers you incentive for your using their product, or attempts to use kickbacks to bias you towards their product, this is consider to be illegal under the False Claims Act. Never accept gifts of any kind of pharmaceutical companies or medical supplies.

#4. It is illegal to retaliate against whistleblowers.

Have you been found liable for fraudulent activity committed in your workplace? Then you can be further prosecuted if you retaliate against the person who reported your fraudulent actions. Therefore, it is crucial that you treat all of your employees fairly. Never terminate or punish someone engaging in whistleblowing activity.

In order to create an ethical workplace, you can encourage in-house whistleblowing among your employees. Reward employees for practicing transparency and honesty in the workplace. If an issue of any kind arises, do not try to conceal it. Instead, quickly report any fraudulent activity by the employees working for you in order to protect yourself from liability. An experienced whistleblower attorney can you protect yourself and your patients against complaints like this.

Have questions about the Medicare False Claims Act? Call the Bothwell Law Group at 770.643.1606.

How Does the Federal False Claims Act Affect Medicare False Claims Cases?

federal false claims act medicare

federal false claims act medicareThere are many ways in which the Federal False Claims Act affects Medicare false claims cases. To understand how this happens, you need to learn what the False Claims Act is, what it covers, and how its enforcement works.

The False Claims Act, like many other piece of legislation, is complex. Interpretation is best left up to the professionals, but those who are looking to hire an attorney should familiarize themselves with the legislation and enforcement so they know what to expect.

What Is the Federal False Claims Act?

The Federal False Claims Act is a piece of legislation that assigns liability to individuals and organizations that defraud programs of the government. This Act is what the government usually uses as a legal basis when suing individuals or organizations for fraud.

It is important to note that the act contains a provision (called a qui tam provision) that allows other people to file actions on behalf of the government. Legislation calls these people “relators” but most of us know them as “whistleblowers.” This provision is very useful, as whistleblowers file a significant portion of suits brought under this Act. In fact, whistleblowers brought 70% of lawsuits. These suits recovered $27.2 billion in the period between 1987 and 2013. Many of these lawsuits related to false Medicare claims.

History of Qui Tam Laws

To understand the False Claims Act and its qui tam provision, you need to look at the history of similar legislation. This history influenced the False Claims Act during its writing and continues to influence enforcement of the Act today.
Qui tam laws date back to the Middle Ages. Specifically, they got their start in England. King Edward II offered one-third of the money recovered from corrupt government officials to those who reported them. This legal practice continued under Henry VIII, who ruled that whistleblowers, or “common informers,” could sue landowners in court for cases related to the titles of different pieces of land. A version of this law is still in force in Ireland, although England has since repealed the law.

The idea of a whistleblower bringing a lawsuit for the public good first appeared in America in the Commonwealth of Massachusetts. The penalties for fraudulent bread sales went to two parties: the person who reported the offense and the town in which the crime occurred. Other states like New York, Connecticut, Virginia, and South Carolina followed Massachusetts’ example.

The Civil War brought about the start of the False Claims Act in the United States. Due to the amounts of money spent by both the Confederate and Union governments, many people involved in the government saw an opportunity to commit fraudulent acts and enrich themselves. Congress passed the False Claims Act on March 2, 1863. As Abraham Lincoln was president at the time, some called it the “Lincoln Law.”

It is important to note that the False Claims Act contained a qui tam provision from the start. This provision is responsible for most of the lawsuits brought under the act, including most of the biggest Medicare false claims suits.

Qui Tam Laws and Medicare False Claims Suits

Up until the 1990s, most suits filed under the False Claims Act related to military spending. However, Medicare has become the focus of enforcement of the Act. The monetary value of the recoveries associated with Medicare fraud reached 40% of the total in 2008.

One of the most influential Medicare false claims suits was Franklin v. Parke-Davis, filed in 1996. The case concerned bills submitted to the Medicare/Medicaid programs by health care providers. They claimed they had provided certain treatment, when in fact, they had not.

It is interesting to note that many Medicare false claims suits filed under the False Claims Act concern the marketing of pharmaceutical companies for off-label (non-FDA-approved) usages of drugs. When Medicare pays for these prescriptions used in non-FDA-approved cases, it constitutes fraud.

Liability for Medicare Fraud under the False Claims Act

The False Claims Act establishes specific circumstances under which a person or organization can be liable for fraud against the government, including Medicare fraud. The most common circumstance is knowingly presenting a false claim for payment. Those who commit this fraud often also fabricate evidence to support their fraud, which is the second provision that often applies in Medicare fraud cases.

Find out more about how the Federal False Claims Act affects Medicare false claims cases by contacting Bothwell Law Group online. Our legal team at Bothwell Law Group has many years of experience working on Medicare false claims cases that fall under the purview of the Federal False Claims Act. This sort of experience is rare and is exactly what people involved in these cases need to seek out.

When to Report Fraud When You Are Aware of Fraud

when to report fraud

when to report fraudWhen to report fraud is a question you may be facing if you are aware of it happening but aren’t directly involved. If you don’t report it, will you be in trouble? There are a lot of unknowns in the world of whistleblowing and fraud. It’s time to dig into it for some insight and to give you direction and peace of mind.

What Do You Mean Report Fraud?

Fraud in this context refers to businesses that fraudulently take money from the US government in a variety of different ways, including Medicare fraud, criminal defense contract fraud, and nursing home fraud, to name just a few of the most common scenarios. There are many different ways people charge government programs for goods and services that are either not delivered or not justified.

Because fraud exists on such a broad level, laws have been created to encourage private citizens to report fraud when they witness it. These rules are known as False Claim Act laws, and they date back to the days of Abe Lincoln and the Civil War. Because people aren’t prone to report things that could cause them a backlash, the False Claims Act includes provisions for the whistleblower to receive a portion of any money recovered in a lawsuit. There are also laws to protect the whistleblower from losing their job.

Some of these laws and protections directly address just when and how we need to report fraud once we know about it. Surprisingly, there is not one simple, easy to understand rule. The law varies according to different industries, and it even changes from state to state.

The important thing to remember is if you are aware of fraud, you are likely obligated to report it, or else you may be found guilty of defrauding the government as well.

When Do I Need to Step Forward and Report Fraud?

Most people who report fraud are employees of the company committing the fraud. For example, one of the most common areas of fraud is within the program of Medicare. If you work in a doctor’s office as a nurse and never touch the bookwork, you probably have no idea the fraud is taking place. If you transfer to the accounting department, however, you may begin to see a problem.

Even if a person is involved in the actual fraudulent activities, they can still be the reporting whistleblower. The law does stipulate that fraudulent charges in Medicare cases need to be brought within 30 days of discovery of the practice. If a person is aware of the fraud and fails to report, they are in danger of prosecution under the law. However, even though the law allows for the prosecution, it rarely actually happens.

Even if a business or individual self-reports their participation in the fraud, they are not exempt from possible prosecution. Often, however, a judge will levy a lower penalty upon a voluntary disclosure of the activity.

How Do Your Report Fraud to the Government?

Fraud is reported with a complaint made in District Court. The best practice for any whistleblower is to hire an attorney familiar with the False Claims Act. Choosing an attorney who works exclusively in this type of law is always the wisest decision.

Because there are so many ins and outs regarding the statutes of limitations, as well as different kinds of both penalties and protections for whistleblowers, it is critical to hire an attorney who understands all of the particulars of this area of law. The attorney will verify the facts in the case and prepare the complaint on behalf of the whistleblower.

Once the paperwork is brought to a district court, it is put under seal, prohibiting anyone, including the whistleblower, from breaking that seal by disclosing anything. The seal protects the identity of the whistleblower at this stage of the process. In fact, the defendant doesn’t even know an investigation exists. The original seal on the case is for six months. This timeframe is almost always extended, giving the government many months or even years to perform their investigations.

Once the inquiry is complete, the government makes a decision whether or not they will intervene, or take over, in the case. If the federal government does decide to step in, they take over the prosecution of the case. The court serves the defendant notice, and quite often a settlement is reached without actually going to court

If You Are Aware of Fraud, Report It to a Whistleblower Attorney

If you are aware of fraudulent billing practices taking place at your place of work, or any organization for that matter, contact an attorney who works in False Claims Act law right away. Even if you are knowingly participating in the illegal activity, you should retain an attorney and file the complaint.

If you are not actively involved and the court determines proof of fraud, you are entitled to between 15% and 25% of the monies recovered. The amount of that reward can reach millions of dollars in some cases. Have questions about when to report fraud? Contact the Bothwell Law Group online now.

Medicare False Claims Act Penalties: Who Actually Pays?

Medicare False Claims Act Penalties

Medicare False Claims Act PenaltiesWho pays when it comes to Medicare False Claims Act penalties? There are laws in place that require real penalties and pay rewards to citizens who report the fraud as well. The False Claims Act penalties exist to recover some of the billions of dollars fraudulently taken annually.

What Medicare False Claims Act Penalties Are There?

Unfortunately, Medicare is the pot of gold for several different types of fraudulent acts that carry strict penalties under the False Claims Act. There are blatant and continual scams being perpetrated. Under the Qui Tam Law, the person who brings these criminal acts to court can also be compensated if the government receives restitution from the case. Some of these include:

  • Billing Medicare for services that were not provided
  • Billing Medicare for services that were not medically necessary.
  • Billing Medicare for services at a standard of care/certification that was not provided to the patient
  • Kickbacks given for referrals of patients in Medicare
  • Self-referral for Medicare patients

Medicare False Claims Act Penalties: How Does This Happen?

One of the largest types of crimes with penalties under the False Claims Act is billing Medicare for services that are never actually provided. Many times this is as simple as it sounds—submitting charges for services no one performs. Often, the deception is done so overtly that the patient files have nothing to back up the charge—no orders, no notation of the patient having been seen, or no follow up. When these cases are prosecuted, they are relatively easy to prove, although direct testimony from patients is needed.

Other fraudulent billing practices include coding issues. Each medical procedure has a code that someone enters into a form for billing purposes. Often an incorrect code is entered, leading to billing for a higher cost service. Human error accounts for some mistakes, of course, but a pattern of errors points to fraud.

Many services are bundled together and given a code as a group. Another type of coding error involves unbundling these services and placing individual charges, which can be significantly higher.

Another fraud consists of bills submitted to Medicare for services that are not medically necessary, such as unnecessary tests, imaging, or equipment.

Some providers will bill Medicare for services at a higher level of care than a patient received. This violation can include charging a specialist fee without the patient consulting with a specialist or charging for an M.D. when a nurse practitioner or physician’s assistant provided the services.

Kickbacks are a widely known type of fraud in the healthcare industry. Kickbacks concerning Medicare include providers who accept payment or reward in return for soliciting Medicare recipients. Many cases involve a health care provider receiving a financial incentive for purchasing special equipment and then billing Medicare for that equipment without revealing the kickback.

Self-referrals are when a doctor refers a patient to a practice in which the doctor is an invested owner. A doctor cannot be financially benefitting from a referral. A referral is done to get a client the best health care, not to increase one’s coffers.

So, Who Actually Pays for Medicare False Claims Act Penalties?

When a fraudulent claim is brought to court and successfully prosecuted, there are penalties to be paid. The penalties are based on the number of counts of fraud, the amount of money recovered, as well as up to three times the programs’ losses.

Every single charge, every single kickback, every single misrepresentation is considered a claim. It’s easy to see how the number of claims can add up quickly. The penalty for each claim is assessed on the amount of damages to the government—in other words, the amount of money Medicare paid out for the fraudulent claims. The liable party must pay three times the amount of these costs. Also, there is a penalty assessed between $5,500 and $11,000, for each claim.

The claim is paid by the person or business found liable for the fraud by the court. It should come as no surprise to anyone that there are insurance policies available to healthcare professionals to help defray these costs. Insurance can be obtained to cover both the defense and the penalties in False Claims Act claims.

If someone is notified of False Claims Act charges, they should immediately tender notice to their insurance provider. If the provider does not tender notice as soon as possible, they are potentially forfeiting their coverage and protection.

If you are looking for more information about False Claims Act penalties and how the Qui Tam Law benefits the person who brings this type of fraud to court, call (770) 643-1606 to learn more by contacting Bothwell Law Group online.

When Does the Medicare False Claims Act Come into Play?

Medicare False Claims Act

Medicare False Claims ActAre you wondering what constitutes fraud under the Medicare False Claims Act? If you’ve come across something unusual in the course of receiving treatment, performing an office audit, or overheard an incriminating conversation, you might have grounds for filing a qui tam lawsuit.

However, it’s worth noting that not every instance of fraud will qualify. To help you determine what is and is not in scope, we’ve outlined the basics of the FCA, as well as additional items to consider before invoking it.

What Constitutes Fraud Covered by the FCA?

There is a hurdle or two that must be met to qualify:

  1. A person or individuals knowingly present (or causes to be presented) a false or fraudulent claim for payment approval by the U.S. Government.
  2. The individual(s) knowingly makes, uses, or causes to be made a false record or statement to get a fraudulent claim paid for, or approved by, the government.
  3. Conspires to do any of the above.
  4. Knowingly makes, uses, or causes to be made a false record or statement aimed at decreasing the dollar amount or other general obligation owed to the government.

One or any combination of the following will make your case eligible for coverage under the False Claims Act.

Common Types of Medicare Fraud

Every year, billions of records are sent to the U.S. government for payment under the Medicare program. Because the system is automated, and the number of transactions is so large, it’s impossible to oversee every single one. As a result, less than 2% of transactions submitted to Medicare ever get audited.

The low audit numbers and lack oversight make it incredibly easy to perpetrate any of the following types of common Medicare fraud:

  • Double billing
  • Up-coding
  • Up-charging
  • Unbundling and charging for services individually
  • Charging for services not rendered
  • Charging for time not spent
  • Charging for nonexistent employees
  • Receiving kickbacks from patients
  • Receiving kickbacks from companies
  • Identity theft
  • And more

Every year people find new and different ways to attempt to defraud the government. Whether it’s prescribing drugs for off-label purposes or using expired heart valves and equipment, the possibilities are nearly endless.

The only thing standing between the crooks and being caught? People like you who decide to report or file suit.

When to File a Qui Tam Lawsuit

While knowledge of intentional fraud is a key qualifier, there are additional items to consider when deciding whether or not to file a qui tam suit. Here are a few of them:

  • Overall size of the fraud scheme
  • The level of your personal involvement in perpetrating it
  • Any extenuating personal ramifications (stress, friendships, relationships, etc.)
  • The amount of physical evidence you have, or have access to

Any one of these items can derail a lawsuit before it even starts. To determine if it’s the right path forward for you, engage an experienced attorney or law firm and have them talk you through the pros and cons of the process.

Looking for Further Assistance in a Medicare False Claims Act Case?

Still have questions about the Medicare False Claims Act? Contact the Bothwell Law Group online, and we’ll help you find the answers you need.

What Is the Process for Reporting Medicare Fraud?

Reporting Medicare Fraud

Reporting Medicare FraudIndividuals reporting Medicare fraud is one of the government’s only lines of defense. The system is so vast; it’s impossible to police every transaction. And as a result, they enacted the False Claims Act, designed to incentivize individuals aware of potential fraud to come forward. The law has morphed slightly over time, becoming more stringent, and with a particular focus on medical billing and practices.

One of the most common types of medical billing fraud is something called up-coding: billing the government for a process, procedure or medicine which costs more than what was administered. Let’s use up-coding as an example to explain how fraud happens, and process for reporting it.

How Up-Coding Happens Without Being Caught

The coding system itself is electronic, with a set of universal codes for every medical charge. Doctors and hospitals submit bills through insurance and the coding system, then on to Medicare. Because of the high number of transactions, Medicare audits less than 2% of the total volume. It’s a system practically begging to be abused!

Now do you see why the government must rely on individual citizens to help identify and report Medicare fraud?

What to Do When You Suspect Medical Claim Fraud

The first thing you need to do is gather proof and information. Any form of emails, letters, voicemails, alternate records, patient files and so forth are critical for reporting fraud. Once you have the information, you can best decide how to proceed next.

When to File a Qui Tam Lawsuit

If the fraud you discover is minimal, your best bet is to go through or the Office of the Inspector General. Likewise, if you suspect the fraud to be significant in size, but can locate very little proof, these may be your best bets.

However, if the scale and size are significant, and your evidence is substantial, you may want to consider filing a qui tam lawsuit under the False Claims Act.

Why You Might File a Qui Tam Lawsuit

In addition to feeling like a good citizen, reporting fraud to your government and helping to recover taxpayer dollars, you also become eligible for a portion of the recovery amount. As much as 30% of the amount covered can be awarded to you as a result of bringing the case to the government’s attention. In large-scale fraud cases, the size of the pie can be larger than most lotteries.

Consult a Legal Professional about Fraud

Your first step the moment you discover a shred of evidence should be to talk to a lawyer specializing in filing suit under the False Claims Act. They can help guide you toward the best solution based on the particulars of your case.

What Not to Do If You Suspect Medical Claim Fraud

Don’t start telling everyone you know you suspect fraud may be occurring. This violates some specific requirements for filing a qui tam suit, specifically that the perpetrator not be made aware of it. The technical term is filing “under seal” and you nullify the opportunity by making your suspicions public… even if the “public” in question is only immediate friends and family.

Ready to Find Out More about Reporting Medicare Fraud?

Still have questions about reporting Medicare fraud? Contact our team at Bothwell Law Group, and we’ll help you get the answers you need to make your decision.

The Process for Lawsuits That Stem from the False Claims Act and Medicare

False Claims Act and Medicare

False Claims Act and MedicareLawsuits stemming from the False Claims Act and Medicare fraud are unique. They follow an entirely different process than normal civil litigation, and it’s important to understand the key differences before filing suit. Because the process is so distinct, you need to have a firm understanding of the ins and outs; otherwise, your suit could be over before it’s even begun.

Here’s a simplified breakdown of how the process works, and how you should proceed as you determine whether or not to file suit:

Gather the Evidence about Medicare Fraud, but Keep Quiet

This might seem like a no-brainer, but hearsay isn’t enough of a reason to go to court. Before you do anything rash, determine whether you have a way to prove your allegations. Needless to say, the stronger your evidence, the more likely you are to receive a favorable judgment or settlement. Anything in writing or in the form of digital files is your best bet: emails, receipts, paper reports, sales records, and so forth.

It’s also critical that you don’t tell anyone about your suspicions, or your possible lawsuit. We’ll explain more about why in a later section, but it’s best to stay mum on your findings until you….

Hire a Lawyer Who’s Got Medicare Fraud Law Experience

You’ll want to interview a few lawyers before settling on the right one. However, you should be looking for someone with a few key characteristics:

  • Experience winning cases comparable to yours
  • They’re straight-forward; they won’t promise you’ll win, but they will tell you the odds and how you can improve them
  • They’ll listen to your goals; if you don’t want to drag out a trial for years, they’ll tell you your options and be willing to adjust their strategy accordingly

Once you have the lawyer, next comes the hard part.

Deciding Whether or Not to File a Qui Tam Suit

There are a lot of things to consider when determining whether or not to press forward with a qui tam lawsuit. Various job, personal and social ramifications are unprotected by the law, and you need to decide if filing this lawsuit is going to be worth it. If you hired an experienced lawyer in the previous step, he or she should be willing to lay these out for you in detail.

If you decide to press forward, this is when you…

File the Fraud Complaint Under Seal

“Under Seal” is a fancy way of saying “in secret.” You and your legal team will file with the Court, who, in turn, alerts the government. The government will then review your materials and launch an investigation. This part is critical; your employer will not be aware they are being investigated. This is precisely the reason we told you to keep your suspicions to yourself early on. If anyone violates the under seal order, it could cause the lawsuit to be thrown out.

The Government Makes a Decision on Whether or Not to Intervene

Based on the size of the prize and the strength of the evidence, the government will determine whether to intervene, or join your case. In other words, they decide if they want to take it over on their own, or let you carry it forward on their behalf.

If they join you, your odds of winning a favorable ruling or settlement go up significantly. However, your portion of the recovery will top out around 20%.

If they don’t join you, you can still carry the suit forward on your own. Depending on your case, you may still have a very strong chance of a favorable outcome. What’s more? Your portion of the recovery can be as much as 30%; a result of the inherent risk you’re taking by going it alone.

The Outcome of False Claims Act and Medicare Lawsuits

Either your case will go to court, or the company you sued will opt for an out-of-court settlement. Either way, you’ve made it to the end of the road, and a portion of the funds is now yours!

Still have questions about the False Claims Act and Medicare fraud lawsuits? Call 770.643.1606 to contact the Bothwell Law Group online.