Medicare False Claims | Bothwell Law Group

Are 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:

A person or individuals knowingly present (or causes to be presented) a false or fraudulent claim for payment approval by the U.S. Government.
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.
Conspires to do any of the above.
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.