Healthcare fraud is a growing issue that costs the United States tens of billions of dollars each year.
As a health care fraud lawyer, I strive to protect patients and health care providers from fraudulent schemes.
Patients rely on me to ensure their rights are protected when seeking medical care. Health care providers trust me to shield them from false allegations of misconduct.
My expertise enables me to assist clients facing audits, investigations, overpayment demands, and other legal issues related to health care fraud.
I approach each case with compassion and fight vigorously for favorable outcomes.
Health care fraud can take many forms, from billing for services not rendered to paying kickbacks for referrals.
Understanding the complex web of laws governing health care is crucial.
With clarity on these issues, I can develop strong defensive and offensive strategies tailored to my clients’ situations.
Though health care fraud is common, it doesn’t have to go unchecked.
As an experienced health care fraud lawyer, I have the knowledge and determination to take on this critical issue.
What are the most common types of health care fraud?
Some of the most common types of health care fraud include:
- Billing for services not performed – This is when a health care provider bills for services that were never actually rendered. Examples include billing for an office visit that didn’t happen or for a procedure that was never done.
- Upcoding – This involves billing for more expensive services than the ones that were actually provided. For instance, billing for complex surgery when only a minor procedure was performed.
- Unbundling – This billing fraud happens when services that should be billed together are split up and billed separately. This makes the total charge higher.
- Phantom billing – Here, a health care provider fabricates patient information to bill for services for a patient that doesn’t actually exist.
- Kickbacks – Kickbacks are payments or other incentives provided to encourage referrals of services that are reimbursable by federal health care programs. This corrupts medical decision making.
Prescription fraud – This includes activities like altering or forging prescriptions, selling prescriptions to drug dealers or abusers, or billing for medications that weren’t dispensed.
What are the penalties for health care fraud?
The penalties for being convicted of health care fraud can be severe. Some potential penalties include:
- Fines – These can range from $10,000 to $50,000 per false claim, plus treble (triple) damages.
- Imprisonment – Depending on the offense, individuals can face up to 10 years in prison for health care fraud.
- Exclusion from federal health care programs – Those convicted of certain fraud charges can be excluded from Medicare and Medicaid. This prevents payment for future services.
- Loss of licensure – In some cases, professionals can lose their licenses and be prevented from practicing medicine or billing federal programs.
- Civil monetary penalties – These fines of up to $50,000 per violation can be imposed for fraudulent acts.
- Restitution – Illicit gains from fraudulent schemes may have to be paid back.
Loss of hospital privileges – Hospitals and health systems can revoke privileges so those convicted of fraud can no longer see patients there.
How do I report suspected health care fraud?
If you suspect health care fraud, some options for reporting it include:
- Contacting the FBI online or by phone. They investigate major fraud cases.
- Filing a complaint with the U.S. Department of Health and Human Services Office of Inspector General (OIG), which investigates Medicare and Medicaid fraud.
- Calling the Medicare hotline or contacting your Medicare plan provider directly if the fraud involves Medicare services.
- Alerting your state attorney general’s health care fraud unit. Many states have dedicated teams.
- Notifying your state medical board if fraud is committed by a medical professional, so they can take disciplinary action.
- Using false claims act lawsuits (qui tam), where whistleblowers with inside information can sue on behalf of government programs to recover losses.
Reporting fraud helps prevent further wasteful losses and protects other patients from harm. An experienced whistleblower attorney can advise you through the process.
What types of providers commonly commit health care fraud?
While health care fraud can be committed by all types of providers, some of the providers that most commonly engage in fraud include:
- Doctors – Doctors may bill for services not performed, alter diagnostic codes to justify tests, accept kickbacks for referrals, or prescribe unnecessary medications.
- Hospitals – Hospitals may bill for unnecessary services, upcode procedures to more complex codes, or charge for services at inflated costs.
- Nursing facilities – Nursing homes have been found billing for services not needed or provided. They may falsify records to collect more reimbursement.
- Home health agencies – Some agencies bill for care that wasn’t provided or was unnecessary. They may bill for higher levels of service than appropriate.
- Medical equipment suppliers – These vendors may provide inferior equipment but bill for higher cost items. They may also submit claims for equipment that wasn’t ordered.
- Pharmaceutical companies – Drug companies may promote medicines for unapproved uses or provide kickbacks to providers for prescribing certain drugs.
While most providers are ethical, a few unscrupulous ones can defraud programs of millions. Strong anti-fraud measures are needed.
What are the laws against health care fraud?
Some key laws and regulations against health care fraud include:
- False Claims Act – This federal law makes it illegal to knowingly submit false claims for payment to the government. Whistleblowers can file qui tam lawsuits.
- Anti-Kickback Statute – This prohibits knowingly paying or receiving remuneration to influence referrals for federally-funded programs.
- Physician Self-Referral Law (Stark Law) – The Stark Law prohibits doctors from referring Medicare patients to facilities they or their family have a financial interest in.
- Exclusion laws – These laws allow exclusion from federal programs for fraudulent conduct.
- Civil monetary penalties law – This imposes fines for fraudulent acts like kickbacks.
- Health Insurance Portability and Accountability Act (HIPAA) – HIPAA includes fraud provisions for healthcare records and data.
Violating these laws can lead to criminal charges, fines, and exclusion from federal health care programs.
What are signs that a provider may be committing health care fraud?
Some potential signs that a health care provider may be engaging in fraudulent activities include:
- Billing for services that you didn’t receive
- Conducting excessive tests, scans, or procedures
- Prescribing large quantities of medications
- Coding office visits with complex diagnoses not justified
- Using diagnosis codes that maximize insurance reimbursement
- Being vague or evasive about treatment plans and costs
- Offering free services, gifts, or other incentives for referrals
- Providing and billing for home health services without an order
- Ordering supplies or lab tests from companies they own
- Falsifying records or signatures
- Billing for non-physician services performed by physician
Patients should review EOBs closely and report suspicious billing. Auditing records helps detect improper coding and billing.
What are some recent major health care fraud cases?
Here are some of the biggest recent health care fraud cases:
- Purdue Pharma settled a case for $8.3 billion over aggressive and deceptive opioid marketing that helped fuel the opioid crisis.
- DaVita, a large dialysis provider, paid $270 million to settle a Medicare Advantage kickback scheme.
- Rehab clinic HealthRight agreed to pay $10 million for fraudulent billings to treat HIV patients.
- Walgreens paid $683 million for inadequately screening questionable opioid prescriptions leading to overdistribution.
- Drugmaker Pfizer paid $2.3 billion and entered a corporate integrity agreement for off-label marketing and kickback violations.
- The DOJ recovered $2.2 billion in funds lost to COVID-19 related fraud, like fraudulent PPP loans and Economic Injury Disaster Loans.
Major settlements demonstrate the extensive financial damages health care fraud causes. Vigilant anti-fraud efforts and enforcement are crucial to deter large-scale crimes.
Key Takeaways
- Health care fraud costs the US tens of billions annually and harms patients.
- Common frauds include billing for unperformed services, upcoding, kickbacks, and prescription schemes.
- Penalties include fines, jail time, program exclusion, and license revocation.
- Providers like doctors, hospitals, and nursing homes often perpetrate fraud.
- Key laws used to combat fraud include the False Claims Act and Anti-Kickback Statute.
- Signs of fraud include excessive services, gifts for referrals, and billing issues.
- Major cases show large settlements from widespread frauds involving opioids, Medicare, and COVID funds.
Conclusion
- Health care fraud is a severe issue that demands attention and enforcement.
- Rampant fraud drains critical funds from programs like Medicare that patients rely on.
- Strong whistleblower and anti-fraud programs are needed to protect patients and recoup lost funds.
- Providers, companies, and individuals must be held accountable through tough penalties to deter fraud.
- Patients should stay vigilant against fraudulent schemes and overbilling practices.
- With comprehensive education, reporting, laws, and enforcement, health care fraud’s burdens on patients and taxpayers can be reduced.
FAQ
Q: What are some early warning signs that a health care provider may be engaged in fraud?
A: Some early red flags include excessive tests or procedures, unusually high bills, aggressive billing practices, offering gifts/kickbacks, heavily marketing expensive services, and significant inconsistencies in record keeping or billing. Patients should trust their gut if something feels suspicious.
Q: Can health care fraud be committed accidentally or does it require criminal intent?
A: Health care fraud does not have to be intentional. Recklessly submitting false claims or showing deliberate ignorance of rules can constitute fraud, even if not purposeful criminal deceit. However, harsher penalties usually apply to intentional/willful violations.
Q: What protective steps can patients take against health care fraud risks?
A: Patients should thoroughly review EOBs and medical bills for errors, look for unusual activity, educate themselves on proper billing codes, ask questions about charges/services, request an itemized bill if needed, only provide necessary medical info to providers, and report any suspicious activity.
Q: What agency plays the biggest role in investigating health care fraud on the federal level?
A: The Department of Health and Human Services Office of Inspector General (OIG) is the main government agency that investigates Medicare and Medicaid fraud on a national scale. They work closely with the Department of Justice on prosecutions.
Q: Are whistleblower laws effective at combating health care fraud?
A: Yes, whistleblower or qui tam lawsuits under the False Claims Act have been highly successful, recovering billions lost to fraud. Strong protections and rewards for whistleblowers encourage insiders to report misconduct that may otherwise remain hidden from authorities.