Individuals 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 Medicare.gov 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.
