If you work for, or have knowledge of, any company violating any laws or regulations pertaining to Medicare and Medicaid, you could be a whistleblower for Medicare fraud. And if these violations fall under the scope of the False Claims Act, you may have grounds for a lucrative qui tam lawsuit; up to 30% of monies recovered if the court finds in your favor.
While the money is certainly a great incentive, active participation and oversight from people most closely involved in the healthcare industry prevents billions of lost taxpayer dollars. In 2014 alone, the Justice Department recouped $6 billion in FCA claims, with nearly half that amount stemming from healthcare fraud.
What Constitutes Healthcare, Medicare, or Medicaid Fraud?
Many businesses and industries receive funds from the federal government both directly and indirectly. This includes hospitals, nursing homes, private physicians, pharmacies, laboratories, medical equipment providers, and many more. Any action that leads to receiving government money, or postponing payment to the government, for fraudulent reasons, is fair game. To make it easy for you, we’ve created a list of some of the most common occurrences:
- Charging for a full prescription, but only partially filling it
- Kickbacks to physicians and other medical providers in exchange for exclusively using certain products, or prescribing specific medications
- Ordering tests that are not medically necessary
- Prescribing drugs or treatment not medically necessary
- Increasing billing prices solely for Medicare or Medicaid patients
- Knowingly providing substandard or defective medical devices
- Knowingly providing substandard medical services
- Falsely diagnosing a more significant medical issue than the one a patient actually has in order to charge for more intense and expensive treatments (commonly called upcoding)
- Changing a prescription to a more expensive treatment as a result of kickbacks
- Falsifying drug research grant information and outcomes
- Charging for treatments, prescriptions or services separately when they can be performed together at a reduced cost (sometimes called unbundling)
- Steering individuals to a specific course of treatment, medicine, or medical company when you have a vested interest in company performance (commonly called self-referrals)
- Double billing both the government and private insurance or the patient
- Falsifying records to meet compliance standards (most common with medical devices and machines)
- Submitting bills to Medicare that don’t apply under the Secondary Payer
- Requesting reimbursement for costs related to non-Medicare patients
- And more…
You can see from the list above the many ways different individuals and businesses can go about defrauding the government. It’s almost impossible to catch it all, which is why the government relies on whistleblowers. Ensuring there is a proper system in place for both the reporting of fraud, and protection of the individual making the claim is the reason the False Claims Act and qui tam provision exist today.
Filing a Qui Tam Lawsuit
If you think you may have knowledge of Medicare, Medicaid, or other healthcare fraud, you should contact a lawyer immediately. They’ll be able to tell you what the options are, and keep you from doing anything that may compromise the grounds for your case. Plus, they can help you gather the information you need to adequately support your lawsuit inside both the Justice Department and the courtroom.
Still have questions about being a whistleblower for Medicare fraud? Call 770.643.1606 to contact the Bothwell Law Group online.