Medicare Fraud

Established by the government, Medicare is a system of healthcare cost reimbursement. This program helps pay for the costs of certain healthcare expenses for individuals 65 years of age or older. With a large program like this, many find it tempting to take more than they should when sending invoices.  Under the Medicare Incentive Reward Program, Centers for Medicare and Medicaid Services (CMS) can pay whistleblowers 15% of the final recovery amount applied to up to the first $66 million recovered.

This means a person could earn up to $9.9 million if CMS recovers $66 million or more from their tip.

Healthcare Fraud & False Claims Act

In 1863 to combat fraud in Union contracts during the Civil War, Congress passed The Whistleblower or Qui Tam statute. Then, in 1986, Congress modernized the Whistleblower statute. They renamed it to the False Claims Act. This is the government’s primary tool to combat fraud. Individuals who report fraud in government programs bring the lawsuit on behalf of the government.

The violations found in Medicare can be:

  • Not reporting overpayments
  • DRG (medical billing) fraud
  • Physician referral violation
  • Not returning overpayment
  • Inappropriate hospital admissions

Common Medicare Fraud

Part B is the area with the most common form of Healthcare Fraud. Medicare Part B is part of Medicare and covers services and supplies that are medically necessary. This can include outpatient care, preventive services, ambulance services, and durable medical equipment. It also covers part-time or intermittent home health and rehabilitative services like physical therapy.

The government pays for Part B services provided by physicians, suppliers, and other healthcare providers on a fee schedule. Under Part B, the Medicare beneficiary is responsible for any applicable deductible or co-insurance requirements. When services are covered,  Medicare will either pay the patient or the doctor (assignment method).

Part B Medicare fraud happens when includes:

  • Billing for services not rendered or products not delivered
  • Billing for services or supplies not ordered
  • Misrepresenting services rendered or product provided e.g. Upcoding, inappropriate coding
  • Billing for medically unnecessary services
  • Duplicate billing
  • Falsifying records to still be in the program
  • Billing procedures over a period of days when all treatment occurred during one visit i.e. split billing
  • Laboratory unbundling when a single group of services is billed as a single service
  • Stark law violations
  • Durable Medical Equipment (DME) Fraud
  • Deliberately submitting claims for duplicate reimbursement in order to get paid twice
  • Completing Certificates of Medical Necessity (CMN) for patients not personally and professionally known by the provider
  • Soliciting, offering, or receiving a kickback, bribe or rebate
  • Claims for services not medically necessary

Part C Medicare Fraud

Medicare fraud also occurs in the Part C program as well.  These can be:

  • Inflated general and administrative costs
  • The intentional failure to pay providers
  • Cost-containment at the expense of patient care
  • Failure to provide necessary services for patients

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.

Learn More

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