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

Can 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.