Since its creation in 1965, Medicare has provided support to seniors and other Americans through its national insurance program. Unfortunately, it is also a common target for fraud. By some estimates, $60 billion in improper Medicare payments are made each year, and very few claims are even audited. This fraud not only diverts valuable resources from those in need, it rips off taxpayers and raises the cost of healthcare.
Newman & Shapiro is committed to fighting Medicare fraud, and we have the experience and resources it takes to get it done. If you have evidence of Medicare fraud, you may be eligible for a reward under the False Claims Act.
Overview Of Medicare
Medicare is a health insurance program available to people aged 65 or older, as well as certain disabled individuals. The program is funded primarily through payroll taxes and premiums paid by beneficiaries. The Department of Health and Human Services oversees Medicare through the Center for Medicare and Medicaid Services.
There are four parts to Medicare:
- Part A: provides coverage for hospitalization and post-hospitalization care
- Part B: for medical costs such as physician supplies and services, laboratory tests, diagnostic and radiology services, and more
- Part C (Medicare Advantage): provides Medicare benefits through a privately managed healthcare organization
- Part D: prescription drug program
What Is Medicare Fraud?
Medicare fraud occurs when healthcare providers submit false claims to the government of medical services and supplies rendered to patients. There is scant oversight to the claims process, meaning only a minimal number of Medicare payments are verified.
Some of the most common types of Medicare fraud are:
- Phantom billing. This refers to billing for services or supplies that were not provided. An example would be X-rays that were never taken. In some cases, the services are billed for patients who are no longer with the healthcare facility or have passed away.
- Billing for unnecessary services. A similar problem, some providers simply exaggerate the need for medical supplies and services. Recently, Genova Diagnostics Inc., a clinical laboratory services company based in Asheville, NC, agreed to pay $43 million over allegations that it billed for medically unnecessary lab tests.
- Upcoding. Medical procedures have codes attached to them, with each one corresponding to a certain price to be paid. Upcoding happens when a hospital or healthcare provider bills for more expensive services than were actually provided.
- Kickbacks. Labs, pharmaceutical companies, and hospitals sometimes offer improper payments to doctors who refer patients to them. Boston Heart Diagnostics Corporation recently agreed to pay almost $27 million over claims it conspired to pay doctors kickbacks disguised as investment returns.
- Unbundling. The practice of unbundling refers to billing separately for services that should be combined. Medicare rules require that certain groups of procedures be performed together and therefore included in a single billing. Unscrupulous providers often bill these individually to increase profits.
- Self-referrals. Physicians occasionally refer patients to medical facilities in which the physician or a family member has a financial interest. This is prohibited under federal law. The anti-kickback statute covers a variety of services such as lab, home health, occupational therapy, radiology, imaging, and inpatient and outpatient hospital services.
These and other forms of fraud are often evidenced by falsified records. Healthcare providers may alter patient records to show they “need” services and supplies they actually don’t. In some of the most egregious cases, providers add personal costs to reports that are submitted to Medicare.
What To Do If You Have Evidence Of Medicare Fraud
A variety of individuals – nurses, doctors, accountants, compliance officers, administrative staff, and more – may have witnessed Medicare fraud. There are many forms of fraud, and the above examples only scratch the surface. If you have evidence of wrongdoing, you could be able to file a complaint under the False Claims Act (FCA).
The FCA is the federal government’s primary tool for going after healthcare providers who defraud Medicare. This is done by what are known as qui tam lawsuits. These suits allow whistleblowers to file complaints on behalf of the government and thereby claim a percentage of the recovered funds as a reward. The amount of the reward varies, but may be up to 30% of the sanctions imposed. The FCA also has anti-retaliation provisions that prevent employers from punishing whistleblowers.
FCA qui tam claims are not like ordinary lawsuits. Claims have to be sufficiently detailed and documented to provide the government with evidence of wrongdoing. The law generally excludes the use of publicly available information, meaning that the whistleblower must have insider knowledge concerning Medicare fraud. Timing is therefore critical, because if another individual reports the abuse first, it could invalidate your claim.
How Can Newman & Shapiro Help?
Our firm has broad experience with FCA claims. We understand not only the technical and legal requirements of qui tam lawsuits, but we know how to present a well-documented and compelling case to the government. Failure to follow all of the rules concerning these lawsuits could disqualify you from claiming a whistleblower reward.
Having an experienced attorney is also critical to negotiating the reward itself. The government evaluates a number of factors in deciding how much to offer whistleblowers. Considering the amount of money that is typically recovered in Medicare fraud cases, you stand to lose a significant sum of money if your compensation is poorly negotiated.
Lastly, we help our clients fight back against employer retaliation. It’s not easy to come forward with evidence of fraud. Newman & Shapiro recognizes that, and we will work to protect your rights.
Contact Our Medicare Fraud Whistleblower Attorney
Whistleblowers are courageous, and their efforts save taxpayer money and help patients. Help protect Medicare from waste and abuse. Give Newman & Shapiro a call today to schedule your confidential consultation.