Whistleblower claims in the healthcare setting are unique. Here’s what you need to know.
Given the size and importance of the healthcare industry, it’s no wonder that it has its fair share of whistleblower claims. Medical services cost a lot of money and many people need them. In fact, it’s almost a certainty that you and everyone you know will utilize healthcare services at some point in your lifetime. With so many people needing in healthcare and the massive amount of money involved, it’s inevitable that fraud will take place.
Here is a list of some of the things you can expect to see in healthcare fraud claims:
Lots of Money at Issue
Healthcare makes up a huge part of the United States economy. In fact, the Centers for Disease Control and Prevention estimates that healthcare amounts to $3 trillion of the United States economy. A lot of money changes hands with all the government programs, insurance companies, medical providers and healthcare companies involved. All of this means that a healthcare whistleblower should expect to see a lot of money at stake. This is good in that it can mean a larger qui tam reward. But it’s bad in that it means guilty parties will spend more time and effort fighting allegations of fraud.
A kickback is a special payment one party makes to another as compensation for an improper benefit. One reason for kickbacks in the American healthcare industry is how insurance companies work. For many patients, they cannot receive specific medical care unless they first get a referral from another medical professional. For instance, if you want to see a neurologist, you may have to first see your primary care physician, who will then provide you a referral to see the neurologist.
In a perfect world, your primary care physician will refer you to a neurologist who will do the best job possible in treating the medical issue involving your brain. But with kickbacks, a sleazy neurologist may provide payments to primary care physicians to send patients their way even though the patients should be going to someone else. The payments the neurologist provides the primary care physician would be a kickback.
In the medical world, special codes exist to refer to specific procedures, tests and services. So instead of the bill spelling out the exact procedure, a special code takes its place. This can streamline billing. But it can also provide an opportunity for fraud. Fraud can occur when someone in the medical billing department uses a code for a more expensive medical procedure or service. Upcoding is simply a way for a healthcare provider to charge a higher price for a given service.
Like many other things you purchase, medical services can come cheaper if you buy them as a part of a package deal. So a hospital might charge $200 for an X-ray and $600 to set a broken bone. Billed separately, the total is $800. But by bundling these procedures that often occur together, the hospital might only charge $700. Unbundling occurs when the hospital separates the two services and charges the hypothetical $800 instead of the $700.
Some doctors, hospitals and clinics get really bold in their fraud attempts. Sometimes they will simply make up a patient and bill the government or insurance company for medical care that did not take place because the patient didn’t exist. A slight variation of this fraud technique is to have a real patient, but bill the insurance company or government for nonexistent medical care. For example, a patient might have gone to the emergency room for a really bad headache and received only an MRI. But the hospital not only bills the insurance company for an MRI but a CT scan as well.
Unnecessary Medical Procedures
Unnecessary medical procedures are widespread in healthcare fraud because they are hard to prove, let alone detect. An unnecessary medical procedure is exactly what it sounds like. But discovering it is difficult because it’s hard to know if something is unnecessary. Using the previous example, a patient complaining of a headache may have a migraine where one dose of a certain medication will make everything just fine. Despite knowing this, the doctor orders an MRI scan, “just to be safe.”
In this hypothetical, it’s hard to know if the MRI scan was unnecessary. Even if someone reviewing the medical records believes something is unnecessary, it may be impossible to prove. The only way to prove it will be for the doctor who requested the MRI to admit they ordered a medically unnecessary test. And the chances a doctor will admit to something like that is practically zero.
Want to Discover More about Fraud in the Healthcare Industry?
As you can see, there are a lot of things you could potentially encounter as a healthcare whistleblower. Click to find out more about whistleblower claims by contacting our team at Bothwell Law Group online.