Types of Fraud

Becoming a Whistleblower, and exposing medicare and medicaid fraud, helps ensure that precious healthcare resources are used as intended.

Becoming a Whistleblower, and exposing medicare and medicaid fraud, helps ensure that precious healthcare resources are used as intended.  Whether used as a means of discouraging physicians and nursing homes from delivering substandard care, or ensuring that health care procedures are appropriately priced and delivered as necessary, Whistleblowers have become an integral check on the healthcare system.  A healthcare system in crisis cannot afford such waste, and becoming a Whistleblower is an honorable way of doing your part.

Medicaid & Medicare healthcare expenditures are approximately 25% of annual U.S. healthcare expenditures, amounting to more than $600 billion in 2008. While physicians are often involved, Medicaid and Medicare fraud can be committed by many different parties, including hospitals, nursing homes, home health care agencies, durable goods providers, pharmacies and laboratories. If a provider receives reimbursement from Medicare and Medicaid, then as a government contractor any fraud they commit is subject to being recovered under the False Claims Act.

Medicaid and Medicare fraud often involve issues such as:

• payments to reward the referral of patients or healthcare services payable by Medicaid or Medicare, including, referral fees, finder’s fees, productivity bonuses, discounted leases, discounted equipment rentals, research grants, speaker’s fees, excessive compensation, and free or discounted travel or entertainment;
  
  
• various types of billing-related fraud, including:
  
  
  • upcoding, which occurs when a health care provider submits a claim for health care services, treatments, diagnostic tests or items which misuse standardized billing codes so as to obtain more money than is allowed by law;
    
    
  • submission of a claim for health care services, treatments, diagnostic tests, medical devices or pharmaceuticals that were never delivered to a valid patient;
    
    
  • unbundling, which involves billing separately for groups of procedures typically performed together, so that a greater total reimbursement can be achieved than would be received from the group, or bundled, reimbursement rate alone;
    
    
  • lack of medical necessity, a fraud where a health care provider submits claims for services, treatments, diagnostic tests, prescription drugs and medical devices that are not medically necessary;
    
    
  • false certification, which occurs when a health care provider or healthcare company states that they have complied with terms of a contract, or other standards of care, so as to get a health care claim paid or to obtain additional business, when they know that such statements are untrue;
    
    
• research grant fraud, involving some combination of providing false information on a government grant application, overbilling costs and other expenses covered by a grant, falsifying research data and results, inappropriate utilization of grant funds and undisclosed conflicts of interest for the principal investigators;
  
  
• the existence of an improper financial interest, whereby a physician or other health care provider has a direct or indirect financial interest in services provided to their patients, including a prohibition on investment interests and compensation arrangements with entities that perform services to which they refer patients or from which they order goods and services paid for by Medicare or Medicaid; and
  
  
• hospitals inflating the costs on their Medicare Cost Reports, or otherwise falsifying the information on these reports to maximize their reimbursement.

Contact Us.

If you have first-hand knowledge of a major medicaid or medicare fraud on the U.S. government, Whistleblowers Against Fraud can help you Maximize Your Whistleblower Reward. Contact us to Blow the Whistle on fraud and receive a free strategic assessment of your whistleblower information.