The size, growth, and diversity of government healthcare programs present multiple oversight challenges; leaving even Federal programs such as Medicaid and Medicare susceptible to fraud. The U.S. Government Accountability Office (GAO)designates both programs “high-risk.” False Claims Act and a number of other laws have been passed to encourage whistleblowers because for every dollar the government spends on fighting fraud in health, it receives $7. We assist whistleblowers successfully prosecute businesses and individuals indulging in fraud., growth, and diversity of government healthcare programs present multiple oversight challenges; leaving even Federal programs such as Medicaid and Medicare susceptible to fraud.

The U.S. Government Accountability Office (GAO)designates both programs“high-risk.”False Claims Act and a number of other laws have been passed to encourage whistleblowers because for every dollar the government spends on fighting fraud in health, it receives $7.We assist whistleblowers successfully prosecute businesses and individuals indulging in fraud.

Common Healthcare Fraud Scenarios

Businesses and individuals defraud state and federal government healthcare programs in many different ways. Common examples of fraudulent conduct include:

  • Services Not Rendered – Submitting a claim for a health care service, treatment, medical device, diagnostic test, or medication that was never rendered.
  • Cost Inflation – Inflating cost reports or falsifying information on them with the intention to maximize reimbursement is another common type of fraud.
  • Ghost Patients – Submitting a claim for a health care service, treatment, medical device, diagnostic test, or medication that was never rendered.
  • Research Grant Fraud – Falsifying research data and results in order to secure a grant. Over-billing and spending grant money for unrelated research is also considered under research grant fraud.
  • Kickbacks – Improperly soliciting (monetary remuneration) healthcare services providers for referring patients or healthcare services payable by a state-funded healthcare program.
  • Upcoding Services – Submitting a claim for a treatment, diagnostic test, or healthcare service representing a more serious and expensive procedure than was actually performed.
  • Red-lining – Refusing to take care of the sickly because insurance companies pay a fixed amount, that is not commensurable with real costs, for their treatment.
  • Bundling and Unbundling – Special reimbursement packages are available for procedures typically performed together. A common way to defraud government healthcare programs is to overlook the package and bill each procedure separately.
  • False Certifications – In order to qualify for payment from the state, physicians, hospitals, and other healthcare providers have to submit a number of documents with bills. Falsifying those documents is fraud.
  • Improper Financial Interest – The Federal Stark law and other anti-referral laws prevent compensation agreements between whereby physicians are paid by health services for referring patients to them.
  • Medically Unnecessary Treatments – To qualify for payment by government health programs, treatments, pharmaceuticals, and healthcare services should be medically necessary. It’s considered fraud to submit claims for medically needless healthcare services.