One of the biggest areas of fraud involves false claims submitted to the federal government in connection with Medicare/Medicaid programs. This also happens to be where some of the largest judgments under the False Claims Act have been rendered. Listed below are specific types of fraud that have been committed in the past with respect to these programs. If you have knowledge of some of these illegal practices, please contact David Pearline at once. You may have a viable claim under the False Claims Act.
No Need for Medical Services: There are doctors who will bill Medicare or Medicaid for medical services that are not medically necessary to perform on the patient. If you are a patient or know of a patient and suspect that a doctor is performing unnecessary medical procedures on you or someone else for which he/she is being reimbursed under Medicare or Medicaid, you may have a viable claim under the False Claims Act.
Services Not Provided: There are doctors who will bill Medicare or Medicaid for medical services that were not provided to the patient. For example, a doctor may bill the government for performing a EKG on the patient that never took place. If you are a patient, or work in a doctor’s office, and you become aware of such practices, you may have a viable claim under the False Claims Act.
Submission of Untruthful Statements: Individuals who submit false statements to Medicare or Medicaid in connection with claims that they make for payment may have violated the False Claims Act. For example, falsely certifying the credentials of health care providers constitutes a violation of the False Claims Act. In addition, health care providers who participate in Medicare or Medicaid agree to abide by the terms and conditions of these programs. Anytime these individuals submit a claim where they know they have not adhered to the rules and regulations of the program, they have implicitly made a false statement that they were abiding by those rules and regulations. If you are aware of any false statement submitted to Medicare or Medicaid, you may have a viable claim under the False Claims Act.
Improper Coding: Medicare and Medicaid have designed a system of numerical codes for procedures performed by health care providers. These codes are used to reimburse the health care provider. Typically, the health care provider submits a claim to an insurance company using these codes, and the insurance company has a contract with the government to pay these claims using government funds.
Some corrupt health care providers change the numerical code on the paperwork submitted for reimbursement so that it no longer corresponds with the treatment given or the diagnosis made. They do this because the numerical code submitted provides for additional compensation than they would otherwise receive. For example, a physician may use a numerical code indicating a patient has a serious heart condition to justify a more expensive heart test even though the patient does not have that serious medical condition. In addition, a provider may bill related tests individually instead of as a group in order to avoid the pre-assigned group rate for those related tests and procedures.
Kickbacks: It is illegal under the Stark Act for physicians to refer patients to entities with which they have a financial relationship. It is also illegal under the Anti-Kickback Act for health care providers to receive kickbacks from other entities for referring patients to these other entities. Such illegal activities frequently result in unnecessary medical procedures being performed or an increased price paid for such procedures. When claims are submitted to the government for payment that involve illegal kickbacks or referrals, the False Claims may also be violated.
Substandard Care: When a health care provider provides care that is so substandard as to be worthless, and seeks reimbursement from the government for such care, the provider is liable under the False Claims Act. Even if the substandard service is not deemed “worthless,” claims for services rendered in violation of the standard of care required by Medicare and Medicaid laws and regulations may create liability under the False Claims Act on the theory that those “costs” are not covered under Medicaid or Medicare laws or that the health care provider has falsely certified that he was complying with rules and regulations governing Medicare and Medicaid. If you are a patient or a family member of a patient who has received substandard care by a health care provider who has submitted claims to Medicare or Medicaid, you may have a viable claim under the False Claims Act.