Healthcare Fraud Schemes in Whistleblower Cases

Below, a False Claims Act healthcare whistleblower lawyer  discusses healthcare fraud in the context of False Claims Act cases including the different types of fraud someone can be charged with. If you believe you may have a whistleblower or False Claims Act case call today to schedule a free consultation.

Healthcare fraud, at least in the context of a False Claims Act case, is anytime the money from a government program is wrongfully used. This type of fraud can be triggered by falsifying the billing, or it can be triggered when a medical provider routinely provides medically unnecessary services.

It can be triggered by services that are so bad as to not really exist at all such as if a nursing home is in such a horrible condition that it didn’t even really provide the service. Illegal medical practices on a regular basis could also be medical fraud.

You may have medical fraud if people who aren’t doctors bill as if they are doctors, if drugs are prescribed in an illegal marketing schemes, or if drugs are just plain adulterated and don’t work or don’t live up to the specifications that they’re supposed to from the FDA. If a device is approved though fraudulent representations about what it will do, all that kind of thing can be healthcare fraud. It’s a very big area, that’s for sure.

What is Medical Necessity Fraud?

Well, medical necessity is the initial requirement for Medicare or Medicaid to pay a bill. You have to be able to establish the medical necessity of a procedure in order for a medical provider to be eligible to receive payment from the government for that service.

And of course, you know, something being medically necessary comes down to a lot of specifics with respect to the individual procedure and the diagnosis, but medical providers have to be able to show that a service that they are providing was in fact medically necessary so they can get paid for it. If they can’t show that, if they do procedures that are  medically unnecessary on a regular basis, that’s when they get into trouble under False Claims Act.

What Are Upcoding Schemes?

Upcoding is really a routine practice of charging more than the service is worth. Medicare and Medicaid rely on codes for almost every kind of medical procedure you could possibly imagine in order to submit bills to the center for Medicare and Medicaid services and receive reimbursement from the government through all these codes.

And, a lot of times if you code a procedure a little bit differently so that it will be a little bit more complicated or require a little bit more work on behalf of the medical professional who provided it, if you do that on a routine basis, an organization can bill an awful lot more money.

And sometimes it’s simple for the billing office that’s just checking off different boxes on a form that’s submitted to the government and all of a sudden their billing a lot more for the same procedures and if you do that on a routine basis, it can be a lot of money.

So, there’s a great temptation to do it. Of course it’s not legal to do it and that’s why there had been a few False Claims Act upcoding cases.