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Reporting Medicare Fraud: Altering Records to Defraud Medicare
One of the most common forms of healthcare fraud is the alteration of records to defraud Medicare, which is a predicate to many violations. Oftentimes, healthcare professionals will see an avenue to make a quick buck and may overbill Medicare for things like upcoding a patient visit, or billing for services a patient neither needs nor ever received. Thus, it’s critically important for insiders with integrity to speak up so that fraud is not permitted to continue unchecked. After all, if you’re aware of the fraud and let it continue the authorities may think you’re a part of the problem, so the sooner you speak with a whistleblower lawyer is better, so that you understand the extent of your rights.
If you work in a healthcare professional’s office, a clinic, or a hospital, perhaps you could be well positioned to act as a whistleblower if you have information about extensive or expensive fraudulent activities taking place. If you are aware of the routine alteration of patient records that lack a legitimate basis, you need to consult with a professional especially if they’re asking for your signature to go on the falsified document. Whistleblowers who blow the whistle the right way, using a whistleblower lawyer, could receive up to 30% of what the government recovers as a whistleblower award.
Medicare fraud can come in many forms, including:
- Billing for patients that don’t exist, also known as ghost patients
- Upcoding a patient visit to overcharge Medicare
- Billing for patient services never rendered or not medically necessary
- Unbundling healthcare items that are traditionally billed together to bill Medicare more times
- Billing for telehealth patient visits never provided.
Blowing the Whistle Under the False Claims Act
The FCA includes qui tam provisions that enable a relator (also known as a whistleblower) with evidence of fraud to sue on behalf of the government. Under the FCA, a whistleblower can recover up to 30% of the recovered funds as a monetary reward and has protections when acting as a whistleblower, providing recourse against various forms of retaliation, should they occur. In the healthcare industry, the FCA serves as a critical defense against fraud and abuse.
Reporting violations under the False Claims Act (FCA) always requires a whistleblower attorney because of the legal details and procedures involved and the courts do not permit an individual to commence a False Claims Act pro se without an attorney. An experienced whistleblower attorney both adds value and also can handle the specific requirements and deadlines of the FCA, making sure your claim is filed correctly and on time and presented in a manner that to intrigue the federal government. The Department of Justice investigates FCA cases, so it’s critical to find a firm who has a background of interfacing with the DOJ or even better has DOJ alumni. They can also help protect your rights as a whistleblower, protect against retaliation, and assist in obtaining any whistleblower awards you may be eligible for.
A Recent Case Involving Alteration of Patient Visit Records to Defraud Medicare
On June 5, 2024, a Georgia healthcare provider made an admission of guilt in federal court during a federal investigation. The defendant was found to have instructed two of her employees to alter documents in response to a request for a civil investigation demand. She allegedly informed them if the requested documents were missing or blank, they should create or sign the records, such as making up progress notes for respective patients. This was a compounded violation, because phase 1 consists of the incomplete records that failed to justify billing Medicare and phase 2 was the additional falsification of records intended to obstruct the investigation.
One of the employees expressed concern that the activity was illegal and quit, while the other complied with the defendant’s instructions. TRICARE, Medicare, Blue Cross Blue Shield, Medicaid, and the US Department of Veterans Affairs (VA) were defrauded by the defendant. As a consequence of her actions, the guilty party may be sentenced for up to twenty years in prison, with three years of supervised release, and a quarter million dollar fine.
It’s important to note here how an innocent employee can be caught up in the scheme and how an employer who asks an employee to backdate records all of a sudden may be facing criminal consequences, which is all the more reason to learn your rights early by consulting with one of the best whistleblower law firms.[1]
How to Proceed
- Document, document, document whatever you can, and any evidence you can but before you do anything that could jeopardize your case, refer to the second point, which is to contact a Medicare fraud whistleblower law firm.
- Contact a Medicare fraud whistleblower law firm to explore your options and determine whether you have a case and gain assistance with gathering evidence the right way, filing, and all other steps of the process.
- A Medicare fraud whistleblower firm can also aid in keeping your name confidential through much of the process by filing a case confidentially under seal, which will give you time to plan for your exit if you want to leave
To recap, altering patient records is a highly illegal practice that can harm patients and pillage the pockets of taxpayers. The FCA provides great protections and incentives for prospective whistleblowers, which should be fully utilized, but can only be utilized through the use of a False Claims Act law firm.
If anyone ever asks you to add something to records that is knowingly false or asks you to engage in a cover up of records by altering them after the fact, you better think twice or you may not just be fined or sued, but may be sent to jail. Sometimes in the elaborate schemes to cover up records innocent employees are coerced by their employer and don’t feel like they have anywhere to turn – well you always have an outline if you avail yourself of a free, confidential consultation with a whistleblower law firm that has a focus on protecting whistleblowers.
[1] Georgia Healthcare Provider Admits to Document Alteration Scheme in Federal Investigation – (mednetconcepts.com)
