Types of Healthcare Fraud That Can Lead to a Qui Tam Claim

Employees, contractors, and anyone who is aware of healthcare fraud may be eligible to receive a percentage of any recovery the government obtains if their disclosure is useful to the government. The False Claims Act authorizes awards, generally between 10 and 30 percent, for disclosing fraud by doctors, medical practices, laboratories, pharmacies, hospitals, and any health company. The fraud must involve payments by Medicare, Medicare, TRICARE, or any agency that pays the medical provider for their services, products, or treatments.

Some awards to whistleblowers have been worth millions of dollars, or even tens of millions of dollars in some cases. There are many different ways medical practices and companies take advantage of the government at the expense of the taxpayer and of the patient including the following.

Fraudulent billing

Some of the schemes medical providers use are fairly obvious. Others are rather sophisticated. False billing includes:

• Billing for medical services that were never provided or products that were never delivered
• Ordering tests that are not medically necessary
• Recommending treatments that are not medically necessary
• Ordering single tests or single procedures that normally would be bundled together
• Double billing
• Falsifying a patient’s condition, forging a doctor’s signature, or other deliberate acts that are clearly illegal
• Splitting the bill for procedures over a period of days instead of billing for just one day
• Submitting bills that should be paid by private carriers
• Falsifying cost reports
• Allowing non-authorized staff to perform medical procedures such as patient examinations
• Upcoding, billing for services at a higher rate when the service should be billed at a lower rate or a less expensive service should have been billed

Violation of federal laws

In addition to the False Claims Act, medical practices and providers may commit fraud if they violate two laws aimed at ensuring referrals are made based on what is in the best interest of the patient, and not what is in the best interest of the referring doctor or anyone the doctor works with.

Stark Law is a law that regulates self-referrals. Doctors (and immediate family members) cannot refer patients to entities such as testing services in which the doctor/family member have a financial interest – unless there is a valid exception.

The Anti-Kickback Statute regulates illegal payments to induce doctors to refer patients. Doctors, medical practices, and medical providers cannot offer, pay, solicit, or accept remuneration that is not the fair market value of the services or products paid. Kickbacks include cash payouts, paying doctors for board memberships or honorariums when the doctor doesn’t do any or much work, waiving deductibles and co-pays when there is no medical necessity, and paying for vacations and expensive lunches.

Violations of Stark Law and the Anti-Kickback Statute are generally also violations of the False Claims Act.

Healthcare fraud can also include falsifying applications for medical research grants or falsifying the data to justify the grant or the continuation of the grant.

At Plattner Verderame P.C., we fight for whistleblowers who often risk their job or even their career to serve the public by disclosing fraud. We explain the disclosure process, work to keep your identity confidential, and prepare your claim so that the Justice Department will consider intervening. We are experienced in health fraud cases, IRS fraud, and other types of government fraud. To review your right to a whistleblower award, call us at 602.783.8793 or fill out our contact form to schedule an appointment.