Medicare fraud occurs often, but here is how you can sometimes spot it.
Medicare 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
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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If you’re considering reporting Medicare fraud or have been the victim of retaliation for blowing the whistle, you may want to consider talking to a Medicare fraud attorney. Whistleblower laws are complex. In order to receive protection, you have to have reported an actual violation. The Medicare laws are complex. Without a strong background in Medicare law, even an experienced attorney may struggle to properly evaluate whether Medicare fraud occurred.
If you are wondering whether you should move forward with qui tam litigation, it is important to understand the facts of the law. A portion of the False Claims Act, known as the qui tam law, allows private citizens to file a complaint against an individual, organization, or contractor who is committing fraud against the United States government.
There are many types of healthcare fraud, and the United States government relies heavily on whistleblowers who report fraudulent activity. Anytime a healthcare provider uses misrepresentation on an insurance claim, this is fraud. The False Claims Act makes it possible for healthcare employees to report evidence of fraud in their workplace. Healthcare fraud costs millions of dollars every year.
As 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.
Before filing a lawsuit under the US False Claims Act, some whistle blowers may be concerned about the legitimacy of their case. Maybe you feel unsure about the evidence you have gathered. Or, maybe you feel confused about the exact definition of fraudulent activity. At Bothwell Law Group, we hope to help you better understand the details concerning the US False Claims Act. It is a very detailed and complicated law. Before moving forward, we will clearly distinguish between fraud and a mistake.
Each year, somewhere between three to ten percent of money spent by the government on healthcare is spent on fraudulent insurance claims. Fraudulent insurance claims are becoming increasingly common. However, that doesn’t mean they have become easy to spot. In fact, the individuals committing Medicare insurance fraud have learned how to hide their fraudulent activity well.
When 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.
Are you looking for answers regarding how Medicare whistleblower rewards are paid? The truth is Medicare whistleblowers can wind up with a very lucrative payout. By seeking qualified representation for whistleblower law and Qui Tam Law cases, a whistleblower’s potential for a payout from the liable parties can be substantial.
Who 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.
Of all cases of medical insurance fraud that occur each year, Medicare fraud is the largest source. In 2014, fraudsters scammed Medicare for over $60 billion, and over 2,000 providers have been caught defrauding Medicare. Pursuing Medicare fraud can be difficult due to the prevalence of fraud as well as the sheer number of people involved in defrauding Medicare.
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.