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HELPING HEALTHCARE PROVIDERS COMBAT FRAUD

 

Are you a nurse, physician, pharmacist, technician, pharmaceutical representative, or other healthcare professional? Do you believe your employer might be defrauding the Medicaid or Medicare program?

 

We Represent Employees with Inside Knowledge of Fraud 

Healthcare and pharmaceutical professionals with information involving fraudulent claims against Medicare, Medicaid, or Tricare must report the fraud to the government.

 

Since these violations are difficult to detect, the U.S. Department of Justice has implemented the Whistleblower program under the False Claims Act (FCA) 31 U.S. Code § 3729. The program encourages healthcare professionals to report original information through cash incentives. 

 

Medicare, Medicaid, and Tricare recover billions of dollars each year and pay out millions in whistleblower rewards. In one case, a whistleblower was paid $96 million for helping to recover $3 billion after revealing the pharma company was cheating Medicare. 

 

Examples of healthcare companies that have been found to defraud Medicare:

 

  • Nursing homes

  • Home healthcare and hospice providers

  • Medical equipment providers

  • EMS service providers

  • Hospitals

  • Research laboratories

  • Pharmacies

  • Pharmaceutical distributers

  • Drug companies  

 

If these companies receive reimbursement from Medicare or Medicaid funds, then they are subject to the FCA. 

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What Is Medicare Fraud?

 

Medicare fraud typically includes: 

·       Knowingly submitting false claims or misrepresenting facts to obtain a federal healthcare payment for which no entitlement would otherwise exist 

·       Knowingly soliciting, receiving, or paying remuneration to reward referrals for items or services reimbursed by federal healthcare programs 

·       Making prohibited referrals for certain designated health services 

Anyone can commit healthcare fraud. Fraud schemes range from solo ventures to widespread activities committed by an institution or group. Even organized crime groups may infiltrate the Medicare program and operate as Medicare providers. 

Examples of Medicare fraud include: 

·       Knowingly billing for services at a level of complexity higher than services actually provided or documented 

·       Knowingly billing for services not furnished, supplies not provided, or both 

·       Knowingly ordering medically-unnecessary items or services for patients 

·       Paying for referrals of federal healthcare program beneficiaries 

·       Billing Medicare for appointments patients fail to keep 

 

What Is Medicare Abuse?

The difference between “fraud” and “abuse” depends on various facts, circumstances, intent, and knowledge. 

 

Medicare abuse describes practices that may result in unnecessary costs to the Medicare program. Abuse includes any practice that does not provide patients with medically-necessary services or meet professionally-recognized standards of care. 

 

Examples of Medicare abuse include: 

·       Billing for unnecessary medical services 

·       Charging excessively for services or supplies 

·       Misusing codes on a claim, including by upcoding or unbundling codes

Some federal laws governing Medicare fraud and abuse: 

·       False Claims Act (FCA) 

·       Anti-Kickback Statute (AKS) 

·       Physician Self-Referral Law (Stark Law) 

 

Please note that reporting directly to the government will not entitle you to a reward.  The rules and procedures for filing for a whistleblower reward require an experienced attorney.

 

 

The Law Office of Sara J. Saba, P.A. is here to help medical professionals report fraudulent activity. Do not hesitate to contact our office for a confidential case evaluation, and to discuss your options and eligibility under the reward program. Call 305-450-8009 today or file your report online.  

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