Medicare and Medicaid Fraud FAQ’s

The following is taken from an interview with a healthcare fraud whistleblower attorney as they discuss fraud within Medicare and Medicaid, to learn more call and schedule a consultation today.

What Types of Companies Receive Medicaire and Medicaid Dollars?

Many kinds of companies receive Medicare and Medicaid funds. People obviously think of hospitals, large nursing care facilities, hospice providers, any hospital or healthcare service providers in the business of providing healthcare to folks who qualify for Medicare, people who are elderly generate a lot of health care which is funded through Medicare.

The other major groups of people that receive the funding in addition to the professionals who work at those places are pharmaceutical companies and medical device companies that provide prescription drugs and medical devices that Medicare covers.

Is There a Difference Between Where the Medicare Funds Go As Opposed to Where the Medicaid Funds Go?

No, there is not a difference in that way generally speaking. There is a difference in terms of the qualifications to receive Medicare versus Medicaid funds. Medicaid funds involve more state control a little bit than Federal than Medicare although in the end bills are usually submitted directly to the Center for Medicare and Medicaid Services.

What Do the Firms that Receive this Money Use It For? Why Do They Receive It in the First Place?

Well healthcare for people who qualify, qualified beneficiaries in Medicare are elderly people and for Medicaid generally people who fall below income thresholds. This is something that government pays for to support healthcare it goes for all manner of appropriate treatment including pharmaceuticals, medical devices, laboratory work, X-rays are covered by government funds in this way. While I tend to focus on and see the abuses in the system  it is worth remembering that the system is there for a reason. It is there to provide healthcare insurance for people who need it. You pay an awful lot of money into the Medicare Trust Fund and you know that is what the money is used for. So, that is why I guess there is fraud. I mean it is a huge and vast landscape of different providers and different services that can be provided legitimately and also a great opportunity for those who want to rip off the system.

What Can Be Constituted as Medicare and Medicaid Fraud?

There are all kinds of Medicare and Medicaid and healthcare fraud. There are other government programs of course like Tricare for military personnel and health plans for other government employee.

Generally speaking there are problems with the billing when the provider will increase the billing or “upcode” as it is called the billing claiming to have performed a more complicated, more expensive service on behalf of the patient than they really do. That creates relatively speaking obvious area for fraud. There are incidents of services as being so bad as to be worthless. There are incidents of people charging for services that are not called medically necessary. You can’t charge Medicare for a service when you can’t justify the medical necessity of providing that service to the patient. You know we have a lot of pressure out there in a lot of places to generate revenue so sometimes some patients are given medically unnecessary services or charged for medically unnecessary services.