As discussed in the previous article, the two most common types of whistleblower lawsuits under the False Claims Act (FCA) arise from defense/military contracts or from medical contracts, particularly (but not exclusively) those involving Medicare. This post will briefly discuss some of the common types Medicare and other medical billing fraud.
Because Medicaid and Medicare rely on accurate coding and reporting from healthcare providers, they are unfortunately ripe for medical billing fraud from unscrupulous practitioners. The most obvious type of false claim is billing for a procedure that was not actually performed. However, a fraud does not have to be quite that blatant to implicate the FCA. Any attempt to upcode, double bill, or bill for unnecessary or useless medical procedures can qualify as a fraud. Federal regulations regarding Medicaid and Medicare are comprehensive, and a healthcare provider’s failure to abide by any of those regulations may lead to a false claim. (A regulatory violation must be “material,” which means that a insignificant or purely technical regulatory violation does not apply). Below are just a few examples of the types of fraudulent behavior that have led to FCA claims by whistleblowers:
- Billing for procedures that are not performed, sometimes called “phantom billing.”
- Taking or offering kickbacks or other payments in exchange for referrals.
- Upcoding, or “billing Medicare for equipment or procedures under a code that was more expensive than what a patient actually needed or was provided.”
- Billing for unnecessary medical procedures.
- Billing for procedures or tests that have no medical value, which is known as a “worthless services” claim.
- Billing based on inadequate medical records, or forged records.
- Billing under another healthcare provider’s billing number.
- Failing to report a change in ownership of the facility, while still billing Medicare for services.
These are just some examples of the types of unlawful behavior that may lead to a valid whistleblower claim under the FCA. It is by no means an exclusive list. If you would like to report a medical billing fraud against the government, call me at (504) 267-0777 or email me here. The initial consultation is always free, and our call is completely confidential and privileged. Whistleblowers may be eligible to recover between fifteen and thirty percent of all fraudulent claims recouped by the government.