Healthcare Fraud Kickback Schemes

The government spends several hundred billion dollars a year on healthcare so they care a great deal about any fraud related to healthcare. Unfortunately, there is still a fair amount of fraudulent activity in many aspects ranging from individual medical practices ordering unnecessary tests and procedures to up-coding or billing particular services that were never actually provided.

Healthcare fraud can cover whether drug companies are illegally marketing their drugs or whether a medical device company is illegally marketing medical devices. There is a wide range of things that are considered fraud within the healthcare industry.

If you are unsure about whether your case is subject to whistleblower laws, consult with a healthcare whistleblower attorney.

Kickback Schemes in the Healthcare Industry


Kickback schemes can work almost any way someone could imagine because the Anti-Kickback statute says that the kickback does not have to be cash. Any inducement to a doctor, to a hospital, or to a medical provider to use a product or receive referrals illegally can be considered a kickback and be illegal under the Anti-Kickback statute. It is a wide area, there is some case law that says any payment made if one reason for that payment was to induce some sort of illegal activity could create a kickback. Someone could have a payment that looks on the surface to be legitimate but may in fact not be.

If someone finds out evidence that it is a kickback then it will be treated seriously. The reason is that one wants to go to the doctor and think they are getting medical advice, not business advice. If they advise one kind of surgery or a type of drug or procedure it can all add up to a large amount of money and big business. Therefore one wants these laws in place to keep their advice to us on a medical basis as opposed to a business basis.

Why are Kickbacks Illegal in Healthcare

The reason that most people think that the Congress enacted the Anti-Kickback statute with respect to health care funds is that they want their doctors to have independent judgment, a judgment based solely on their medical conditions and not based on any decisions with respect to business. They want to go to the doctor and want that doctor to understand their ailment and not to be making medical decisions because if they refer a patient to one ambulatory surgical center, they get money back.

A person wants medical advice to be medical advice and not based on some compromising business arrangement from whoever the medical provider is with some other organization. That is why kickbacks are illegal under healthcare and heavily prosecuted under the False Claims Act.

Overbilling Schemes

Overbilling can work in a number of ways. There have been cases where healthcare providers have simply billed for services they did not really provide. There have also been cases where healthcare providers billed for services that they provided but were not at all needed. There have been cases of healthcare providers using their billing forms and they have codes and if they mark the most complicated version of the service provider as opposed to the actual service that was provided they have upcoded the bill. They get more money from Medicare. There are different ways that Medicare can be overbilled for services which include an aspect of fraud.

Difference Between Reporting Fraud and Reporting Medical Malpractices

You can sue in court for negligence in a medical sense. A doctor may not have done the best job they should have or may not have done a job up to the standard of care that they are supposed to provide that is medical malpractice type of case.

Fraud against the government is a little bit different. It is not the question of the doctor or any healthcare provider really making a mistake. They have to be involved in some kind of a scheme that is designed to take money from the government that is not earned.

That is different and it also involves showing that the government was somehow paying for the services. If you went to the doctor and paid them money of out of your money there really would not be a False Claims Act issue. It is a different kind of determination as to the wrongful activity that gives rights to sue.