Medicaid provides health coverage to millions of Americans. This includes low-income adults, children, pregnant women, elderly adults and people with disabilities. States and federal government fund Medicaid, and the state administers the program.
Types of Medicaid Fraud
Medicaid fraud is very common, and the types of fraud can be extensive. Here are just a few of the most common types of Medicaid fraud cases that result in large whistleblower rewards:
Ambulance Fraud occurs when a healthcare provider bills Medicaid for ambulance transportation when a patient could be transported by wheelchair van instead. The patient does not need an ambulance if he or she can walk or sit in a wheelchair. Ambulance fraud also includes billing for patients who do not have valid Physician Certification Statements (PCSs). Someone alters these statements, fakes them or includes fraudulent trip reports.
Coding Violations happen when an improper billing code is purposely used to receive a higher reimbursement rate from Medicaid. The violations include:
- Upcoding, which is using a higher code value
- Unbundling, which is billing separately for services instead of together
- Double-Billing, which is billing Medicare and private insurance for the same service.
Dental Fraud includes billing for items not medically necessary. Other fraud cases include splitting claims or billing for multiple office visits when there was only a single visit.
Durable Medical Equipment Fraud
Durable Medical Equipment (DME) Fraud includes prescribing or billing for DME that was not medically necessary or was not actually provided to the patient. Also, DME Fraud includes billing for more expensive equipment than the patient received.
Home Health Care Fraud
Home Health Care Fraud includes billing for more time than was actually provided. Another is saying a more-experienced professional performed the job when a less-experienced person actually provided the service. Sometimes a company claims reimbursement for a Registered Nurse (RN) when a Licensed Practical Nurse (LPN) provided the services, or when a company claims reimbursement for a Physical Therapist (PT) when a Massage Therapist provided the services.
Kickbacks are when doctors or health professionals receive anything of value for patient referrals. This doesn’t just include money. It can be expensive dinners, tickets events, vacations and more.
When a pharmacist bills for medication never given to a patient or said a high-priced drug was given instead, this is Pharmacy Fraud.
When a doctor has a financial interest in a referral, this is fraud. A financial interest includes an ownership interest, an investment interest, or a compensation arrangement. This can be non-monetary arrangements like staffing and office space rental breaks.
The Law Protects and Rewards a Whistleblower
When a knowledgeable attorney like those found at The Michael Brady Lynch Firm files a False Claims Act lawsuit, he or she files it under a seal. This means it is completely confidential. There is also a full disclosure statement in the suit, which details the evidence collected by a whistleblower.
After we file your suite, the Department of Justice will review the evidence before deciding to step in and decide if they want to prosecute the case. The government’s fraud investigator will work closely with you, the whistleblower to identify all responsible for the fraud.
You could be entitled to 15-30% of the funds recovered. In order to receive the reward, you must be the first one to file a case under the False Claims Act. This is why it is key to pick an experienced attorney to work quickly get your compensation.