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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.

Want to Learn How to Better Spot Medicare Fraud?

Contact our skilled Medicare fraud attorneys at Bothwell Law Group by clicking or calling 770.643.1606 today.

Why Would I Need a Medicare Fraud Attorney?

Medicare Fraud Attorney

Medicare Fraud AttorneyIf 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.

What Does a Medicare Fraud Attorney Do in a Whistleblower Case?

A Medicare fraud attorney’s job is to help you determine whether a Medicare violation occurred. If you are considering blowing the whistle, you may need help to prove that a violation occurred. The Medicare system is complex. Therefore, it is easy to feel that something is not quite right when a company is actually in full compliance with the law. Speak to a Medicare fraud attorney about the situation to find out whether an actual violation occurred. They can help you avoid a situation where you lose your job because of a mistaken fraud report. It’s important to know what whistleblower laws protect – and what they do not protect. Because of attorney-client confidentiality rules, you can almost always ask your own attorney for advice. That’s true even if you have a nondisclosure or confidentiality agreement with your employer.

Have you already made a report? Your employer will likely do everything they can to prove that no violation occurred. They will likely call on an experienced legal team who will work hard to find every possible defense and loophole. If they succeed, you may lose whistleblower protections. Working with your own experienced attorney can help. This way, you can ensure your claims are evaluated on their merits and not by your employer being able to outmaneuver you legally.

How a Medicare Fraud Claim is Evaluated

Medicare fraud typically involves some sort of false statement by a company. They may over-bill for services rendered or bill for services they never rendered. They may also engage in price-fixing. Finally, they may follow other non-competitive practices while claiming to operate under fair and open practices that give patients the best rates possible under market conditions.

When a fraud allegation is made, they will typically produce the falsified records as proof that everything was done properly. The key to proving a fraud claim is understanding how to exploit weaknesses in these documents. Furthermore, success depends on knowing how to use the available legal procedures to secure additional evidence that undermines the validity of these documents. This can be a monumental task for a layperson, especially if you are simultaneously fighting for your livelihood.

To schedule a consultation with an experienced Medicare fraud attorney, contact Bothwell Law Group today.

Are the Rewards Worth the Risk for Qui Tam Litigation?

qui tam litigation

risk for Qui Tam LitigationIf 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.

Fraud can take many forms. Do you have knowledge that your physician is billing Medicare for services you weren’t provided? You can report this fraud under the qui tam law. Or, if you have knowledge that a contractor employed by the government is abusing their authority or grossly misusing government funds, this can also be reported under the qui tam law.

Becoming a whistleblower is not without risk. There are laws in place to protect individuals who report fraud from retaliation such as termination or discrimination in the workplace. However, there are still consequences to publicly reporting fraud.

What risks come with qui tam litigation?

As a private citizen reporting fraud, your identity is only kept confidential until the lawsuit is filed. Once the lawsuit becomes public knowledge, your identity will be revealed along with the details of the fraud. Because of this, you will gain a public reputation for being a whistleblower. Even though many will admire for your actions, some will not see your actions as admirable. This could affect your career, as your employers may see you as untrustworthy or loose-lipped.

Depending on the exact details of your lawsuit, friends and family may not approve of your actions. They may hold it against you, or think you are only reporting the fraud because you want the money.

Are the rewards worth the risk for qui tam litigation?

It is ultimately up to you to decide if you believe the rewards are worth the risk for qui tam litigation. If the government is able to recover fraudulently obtained funds, you are eligible for a reward for your actions. The qui tam law indicates that private citizens who report fraud in a qui tam lawsuit could receive between 15 and 25 percent of the recovered funds.

You could receive a financial reward. Also, you will have the satisfaction of knowing you played a role in recovering government funds. Fraud costs the government millions of dollars each year. Honest and brave citizens play a crucial role in recovering those funds.

Are you a private citizen with evidence of fraud against the United States government? You can become a whistleblower under the qui tam law. With the help of an experienced whistleblower law attorney, you can file a lawsuit on behalf of the government and play an important role in recovering illegally obtained government funds.

Call 770.643.1606 to find out more about qui tam litigation by contacting Bothwell Law Group.

What Types of Healthcare Fraud Are Most Commonly Reported under Whistleblower Legislation?

Types of Healthcare Fraud

Types of Healthcare FraudThere 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.

If you are an employee at a healthcare organization, you can keep an eye out for these most commonly reported health care fraud activities and aid in recovery of government funds:

Health Care Fraud Scheme #1: Billing for Service or Product Never Provided

In some cases, physicians or billing departments will attempt to collect additional money by billing Medicare or Medicaid for services or products they never provided to a patient.

Health Care Fraud Scheme #2: Separate Billing of Services Normally Bundled as One

Many diagnostic tests and procedures are commonly bundled together as one on insurance claims. In some cases, healthcare providers will bill for the bundled procedure and then unbundle the service and bill for each test individually in order to obtain double payment.

Health Care Fraud Scheme #3: Double Billing

In some cases, healthcare professionals may try to bill for a service more than once, as a way to make more money.

Health Care Fraud Scheme #4: Incorrectly Diagnosing a Patient

There are some healthcare services that are only provided by Medicare or Medicaid when the patient has a specific diagnosis. In order to obtain payment for a higher paying procedure, some health care professional may falsely diagnose their patient.

Health Care Fraud Scheme #5: Billing an Uncovered Service as Covered

This type of fraud often happens when a physician is doing a favor for a patient. They want to provide a non-covered service for the patient. Therefore, they bill it as a covered service. Even though motivated by their desire to help out their patients, it is still healthcare fraud.

Health Care Fraud Scheme #6: Accepting Kickbacks from Vendors

The pharmaceutical and medical supply industry is a highly competitive business. Because of this, some vendors may engage in unethical activity to bias physicians to use their product. Anytime a physician accepts a kickback or bribe from a vendor, they commit healthcare fraud.

Health Care Fraud Scheme #7: Use of Unnecessary Services

In some cases, physicians will provide patients with unnecessary services or products normally paid by Medicare or Medicaid. This allows them to receive payment for services they never should have performed.

If you work at a healthcare organization and you suspect your employer may be committing one of the fraudulent activities listed above, you can file a complaint under whistleblower legislation. The laws in place enable to whistleblowers to file a lawsuit on behalf of United States government. Whistleblowers can receive protection from retaliation at the hands of their employer. Also, they may receive a portion of the recovered funds.

Have questions about the different types of healthcare fraud that exist? Click here to get the answers you need from our team at Bothwell Law Group.

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.

Differences between Fraud and Mistake Under the US False Claims Act

US False Claims Act

US False Claims ActBefore 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.

What Is a Mistake?

In some cases, business owners may not be unethical or malicious. They may simply be terrible business owners. It is true that in some cases mistakes may result in the government losing money. However, we should be clear: a mistake is not the same as fraud.

How Is a Mistake Different from Fraud?

To put it simply, fraud requires knowledge of the consequences of your actions. Under Section 3729b of the US False Claims Act, the law is very clear. In order for fraud to occur the person must have knowledge of the laws regarding their actions, whether or not they are intentionally defrauding the government. Even if the purpose of their actions is not fraud, if they are aware of the laws regarding their choices, their actions will still be considered fraud.

If you are thinking the difference between a mistake and fraud under the false claims act seems to be a very fine line, you are right. For employees, who typically do not have professional experience with whistle blowing, it can be hard to distinguish between the two.

What Should You Do If You Suspect Fraud?

Because of this, we instruct any employee working in healthcare who suspects their employer may be committing fraud to gather any available evidence concerning their employer’s behavior. Next, we recommend employees who suspect fraud to play it safe by speaking with an attorney who has extensive experience working with Medicare fraud related lawsuits and who has thorough knowledge of the US False Claims Act.

An experienced false claims attorney can take a careful look at the evidence you have gathered. Then, they can make a suggestion about whether or not you should move forward with your claim. At Bothwell Law, our attorneys understand what it takes to have a successful Medicare Fraud lawsuit. We would never recommend moving forward if we did not believe you had adequate evidence of fraud.

Why You Should Get an Attorney

Working with an experienced attorney with experience in fraud can provide you with peace of mind and confidence, so if you are ready to move forward you can do so without worry. If we have determined you have substantial evidence of fraud, we will guide you through each step of the process.

Have questions about the US False Claims Act? Click to contact the Bothwell Law Group online.

How Insurance Agents Identify Fraudulent Insurance Claims

fraudulent insurance claims

fraudulent insurance claimsEach 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.

What Are Some Signs of Medicare Fraud?

The United States government relies heavily on individuals who are willing to blow the whistle on providers who are committing fraud and stealing money from Medicare. Because of this, insurance agents are learning to be hyper-vigilant. They watch closely for suspicious activity in each and every claim they manage. Insurance agents are learning to identify fraudulent insurance claims by watching for the most common types of Medicare insurance fraud, which include:

Duplicate Billing

In many cases, healthcare professionals will try to bill for a service more than once as a way to make more money.

Separate Billing of Services Normally Billed as One

There are specific procedures, such as diagnosed blood tests, which are typically billed as one. For instance, a complete blood count contains multiple tests but is almost always billed as one procedure. Healthcare providers may bill the CBC tests as one, and then bill for each test in order to receive double payment.

Billing for Services Never Received

In some cases, healthcare professionals will bill Medicare for services a patient never received. Medicare insurance agents can watch for billings that seem out of place or do not match up with a patient’s health history.

Medicare ID Sharing

More frequently, Medicare ID numbers are being shared among multiple people. Healthcare providers may also use them to bill for services for patients they haven’t seen. Insurance agents watch carefully to make the ID number being uses matches with the name on the claim.

In addition to watching for the most common types of Medicare insurance frauds, insurance agents carefully consider the calls they get from Medicare clients. People may call with concerns or confusion concerning a claim description they received in the mail. This red flag signifies the possibility of fraud. The client is the most reliable source for understanding which billings are accurate. So, insurance agents should never dismiss their concerns about inaccurate billing.

What Should You Do If You Suspect Fraudulent Insurance Claims?

If you are an insurance agent or patient who has concerns about a health provider, speaking with a fraud attorney who has extensive experience working with fraudulent insurance claims is a good place to start. A team member at Bothwell Law Group can look carefully at your suspicions. Then we can help you determine whether you have grounds for a lawsuit.

Contact our skilled fraudulent insurance claims attorneys at Bothwell Law Group by calling 770.643.1606 today.

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.

How Are Medicare Whistleblower Rewards Paid?

How Are Medicare Whistleblower Rewards Paid

How Are Medicare Whistleblower Rewards PaidAre 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.

What Is the Whistleblower Law?

The whistleblower law is part of the False Claims Act, which was created in 1863 to crack down on Civil War profiteering. The False Claims Act was revamped and amended by Congress in 1989, making it more accessible and rewarding for any citizen to report false claims against the government. In essence, the law provides both reward and protection from retribution for someone who reports a validated fraud against the government or against public interest.

Whistleblowers, those who speak up about illegal practices affecting government agencies and other industries, have often been silenced by various forms of retribution including job loss, promotion freezes, blacklisting, and many other damaging practices.

The whistleblower law encourages citizens to come forward and inform the government of such fraudulent acts by protecting them from these consequences. The addition of the Qui Tam Law extends these rights by allowing the whistleblower to be rewarded financially, based on the amount recovered by the government in the court action.

How Does Qui Tam Work?

The Qui Tam Law allows an individual, known as a relator, to bring a lawsuit based on claims against the False Claims Act. The citizen, with a lawyer who is knowledgeable about the False Claims Act, brings the evidence to the court and asks the court to investigate the claim.

A relator is someone who has first-hand knowledge about the fraud. They will have access to documents to prove the claim. A Qui Tam claim is kept under seal, confidential, for at least 60 days, initially, although it is not uncommon for the court to extend this time. During the investigation, the entire matter is kept secret. The individual(s) being investigated are not made aware of the allegations or the inquiry.

Evidence in these cases can include things like shipping reports, invoices, bidding information, profit information among many other types of documents. The evidence must be first-hand, direct knowledge, supported by documents. If the court decides there is ample evidence to proceed, they will intervene, and they will then prosecute the case.

You remain a party to the case and cannot be dismissed or removed from the case without a hearing. If the government does not intervene, you can continue the case without them, through your whistleblower representation lawyer. It is much harder to win without the government intervention, but if you do, the reward is higher.

How Are Medicare Whistleblowers Paid?

The relator- whistleblower- is paid via a system determined by the False Claims Act. It begins with the court determining the amount of the penalties owed by the provider or practice. As a part of the lawsuit, the number of violations is added up. The letter of the law states that every single line of billing that is fraudulent is a separate violation, even if there are 25 on a single form. However, many courts have determined that each form is a violation, even if there are 25 separate entries. Once the number of violations is clear, the formula comes into play.

For each count, there is a penalty of between $5,500 and $11,000. Also, the amount of money the government was defrauded is refunded times three. When you consider that a winning case in court probably has hundreds or thousands of claims, the penalties can add up to tens of millions or even hundreds of millions of dollars in some cases.

The relator- the whistleblower- is awarded from 15-30% of the money recovered by the government. The potential for a very large reward is clear. It is not unusual for whistleblowers to receive rewards in the millions of dollars on large, high profile claims.

Some of the highest payouts ever made to whistleblowers include Medicare fraud. In 1999, Whistleblower George Courto, who worked for Bayer, filed a Qui Tam action against his employer and GlaxoSmithKline for selling relabeled drugs to an HMO on the cheap and not reporting the information to avoid paying millions of dollars in rebates to Medicaid. The total payout came to $344 million dollars and $34 million went to the estate of the whistleblower. In another Medicare case, GlaxoSmithKline paid out $333 million in penalties. The whistleblower here received over $53 million.

If you work for any provider that bills to Medicare and you are concerned about fraud issues, you should talk to an attorney who can help. The best way to know if an actual crime is being committed, and to keep yourself protected in the event of a blame-game, is to speak with an attorney who deals exclusively with whistleblower Qui Tam cases.  Have questions about how Medicare whistleblowers are paid? Click to contact the Bothwell Law Group online.

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.

Top Medical Insurance Fraud in the News

Medical Insurance Fraud

Medical Insurance FraudOf 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.

What Is Medical Insurance Fraud?

Medical insurance fraud occurs when a provider or consumer intentionally submits fraudulent information that is used to determine health care benefits payable. Because of the cost of health care and medical equipment, the idea of pocketing the payout of billing for services or equipment that were not rendered is a tempting one for providers and consumers alike. While Medicare is the organization that is most affected by fraud, it can affect any heath insurance company, and can be perpetuated by individual doctors as well as organized groups.

Medicare and related government-provided coverage is the most common target for insurance fraud for a few primary reasons:

  • Over 54 million people are covered by Medicare, and the organization pays out over $600 billion each year.
  • The organization is subjected to the loosest monitoring by those in charge.
  • Billions of dollars are left largely unguarded and ripe for targeting by scam artists.

How Is Medical Insurance Fraud Perpetuated?

There are various ways providers and consumers can commit medical insurance fraud. Some of the most common seen by investigators include the following:

  • Billing for medical equipment, medication, or services that were not actually rendered, received, or performed.
  • Falsifying a patient’s diagnosis to justify procedures, equipment, surgery, or other procedures that were not medically necessary.
  • Upcoding and Unbundling. Upcoding is billing for a service more costly than the one performed. Unbundling is the billing of each step of a procedure as separate procedures.
  • Accepting kickbacks in exchange for patient referrals.
  • Waiving co-pays or deductibles and over-billing the insurance company.
  • Forging or alteration of medical bills or receipts.
  • Using someone else’s health coverage or insurance card.

Combating Medical Insurance Fraud – a Lengthy Process

Medical insurance fraud is a crime that has serious ramifications for everyone. Every time fraud is committed, it raises the cost of health care for millions of other Americans. So it is important that medical insurance fraud is pursued and prosecuted in order to recoup the amounts that were defrauded.

The challenge in pursuing insurance fraud is finding individuals who are both willing to cooperate with investigators and who have sufficient evidence to back up their claims. Even when a whistleblower contacts authorities with information, it can be a long and arduous process to gather more evidence and bring a court case. But these cases must be pursued in order to help combat the rapidly-rising costs of health care in the United States.

If you have witnessed or participated in medical insurance fraud, you will need protections should you choose to come forward as a whistleblower. Contact the skilled whistleblower attorneys at Bothwell Law Group by calling 770.643.1606 today.

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.