Common Types of Frauds in The Healthcare Industry Reported by Whistleblowers

Every year the American taxpayer is cheated out of billions of dollars as a result of fraud, such as systemic Medicare Fraud and Medicaid Fraud. The fraudulent activity occurs in all industries as people wrongfully think the government isn’t watching.  There are all sorts of mechanisms to ensure that companies and people don’t cheat the government and various whistleblower laws to award people with targeted information to come forward with their whistleblower case.

Take a recent case against Spa Castle Inc, for example, a company who committed tax fraud and  settled for $2.5 million under the New York Tax Whistleblower Laws which allow private citizens to commence whistleblower actions to hold tax cheats accountable.  The tax whistleblower in this case received a $575,000 New York Tax Whistleblower Award for reporting on how the massage parlors failed to report income, thereby failed to pay taxes, thereby cheating the taxpayer out of money.  The IRS has a whistleblower program as well, where if the insider has very specific information regarding over $2 million dollars of tax fraud they may act, but it must be very detailed insider information.

However, the most common industry where fraud against the government occurs is in the healthcare industry – with fraud such as hospitals and medical facilities submitting false claims such as providing unnecessary treatments, upcoding, using unlicensed individuals, engaging in kickbacks schemes and a host of other violations meant to cheat Medicare of Medicaid or private insurance out of money.

Types of Healthcare Fraud

There are different types of fraudulent activities that occur within the healthcare industry. Some cost the government more than the others. Understanding the types of healthcare fraud and how to recognize such fraud is important for whistleblowers. The ability of a whistleblower and the government to bring a claim are governed by the False Claims Act (FCA).

False Billing

False billing or billing for services not rendered is a relatively common type of fraud that occurs in the healthcare industry. This involves a physician or treatment facility, including care centers and hospitals, submitting claims to Medicare or another federally funded policy for services that were not provided to a patient. In some cases, the fraud would go as far as to forge a signature in order to make such false claims or doctor a chart to justify the bill.

Providing Unnecessary Treatments and Services

Many doctors and health care facilities have been found guilty of providing treatments that are unnecessary, with the sole purpose of committing Medicare Fraud and Medicaid Fraud and billing their insurance policy for the services rendered.  Medical necessity cases can be difficult to prove if reasonable minds disagree regarding the extent or course of the treatment.  One such example is the case against a doctor for falsely diagnosing patients with skin cancer in order to initiate unnecessary treatments on the patients when insured through Medicaid or Medicare.  There are many examples where the medical provider reflexively bills everyone for treatments that walk through the door, whether they need it or not.  For example, the Doctor may ask do you ever have a headache and when almost anyone answers yes, they might feel your temples and bill for a detailed cranial test or reflexology.

Double billing refers to scenarios where a medical provider bills a patient’s healthcare policy for two visits when the patient only had one appointment with the doctor. The doctor would often use a duplicate of the original claim for the “real” appointment and change a few details, such as the date, and then submit the same claim again.

Service or Item Upcoding

Services rendered by healthcare providers have specific codes assigned to them. Some codes yield higher payouts for the provider from a federally funded policy. The same goes for the prescription of medical devices. Some healthcare providers would submit a higher code to a patient’s healthcare provider than the code of the item or service provided to the patient with the sole purpose of additional profits.

Conclusion

The government relies on whistleblowers to come forward with concrete information to hold accountable many of these tax cheats, Medicare frauds and other cheating of the government and insurance.  Most False Claims Act whistleblower cases are filed against hospitals, care centers, physicians, or other parties in the healthcare industry. Double billing and claiming for unprovided services are common types of fraud committed by them. Whistleblowers play an important role in uncovering such fraudulent activities and helping the government retrieve ill-gotten funds. In turn, whistleblowers may be entitled to a whistleblower award for their information. Under the False Claims Act, the whistleblower must use a whistleblower law firm.  If you believe you have information regarding Medicare Fraud, Medicaid Fraud or many other types of fraud against the government you should consult with a whistleblower law firm like Brown, LLC led by former FBI Special Agent Jason T. Brown to go over your rights and determine how to make your case.

References

https://ag.ny.gov/press-release/ag-underwood-and-acting-tax-commissioner-manion-announce-criminal-conviction-and-false