Medicare and Medicaid are programs that provide health coverage to qualifying individuals. Those who abuse these programs by committing fraud end up costing taxpayers billions of dollars and even put the program beneficiaries at risk. As these programs continue to grow and serve more people, the risk for fraud grows too.
Fraud and false claims committed against the federal Medicare and Medicaid programs are among the most common types of False Claims Act violations. Billions of dollars have been recovered under the qui tam provisions of the False Claims Act as a result of this type of fraud, but billions more have likely gone undetected.
Medicare and Medicaid fraud is illegal. If you are aware of any fraudulent behavior, you have a duty to report it. You may even be eligible for compensation if a successful claim is brought against the dishonest party.
Contact experienced false claims attorney James H. Shoemaker today at 757-223-4580. Mr. Shoemaker provides dedicated legal representation to clients in Virginia Beach, Hampton Roads, Washington D.C., and throughout the United States.
Medicare vs. Medicaid
Medicare is an insurance program that serves a wide range of individuals, including those age 65 or older, younger people with disabilities, and dialysis patients. Medicare is a federal program.
Medicaid is an assistance program that serves low-income individuals. State and local governments run this federal-state program within federally established guidelines.
These programs are often the only way that many Americans can get the medical care and treatment that they deserve. But individuals, companies, health care providers, and other parties take advantage of these programs every day, committing scams and otherwise abusing these programs.
Examples of Medicare and Medicaid Fraud
Providers, patients, insurers, and other parties are all capable of committing Medicare and Medicaid fraud. Fraud often involves someone illegally manipulating the system to benefit financially.
There have been different types of cases in which companies and individuals have cheated Medicare and Medicaid. The following are general examples of the types of fraud that have been committed in the past:
- Fraudulent upcoding of services provided
- Unbundling/fragmentation of services to obtain higher rates
- False cost reports
- Off-label marketing of pharmaceuticals and medical devices
- False charges for services not actually rendered
- False charges for services that were not necessary
- False claims made by pharmaceutical companies
- Kickbacks to physicians to prescribe their drugs
- Engaging in off-label marketing
- Misreporting the "best price" or "federal price" these companies report to Medicare and Medicaid programs
- Providing substandard or tainted drugs
- Residents billing for services that only attending physicians are allowed to bill for
This is not an extensive list of all of the types of Medicare and Medicaid fraud. Unfortunately, people find many cunning and deceptive ways to manipulate and defraud the system. Mr. Shoemaker knows how to recognize fraud in all of its forms, and can examine your situation to determine if there is an actionable case.
How Common Is Medicare/Medicaid Fraud?
The National Health Care Anti-Fraud Association estimates that Medicare and Medicaid fraud cost the U.S. $68 billion every year. This is 3% of the country’s annual spending on healthcare. Other estimates of fraud are as high as 10%.
The most common types of Medicare or Medicaid fraud include billing for never-performed or unnecessary procedures, billing for unnecessary tests, and billing for unnecessary equipment.
What Are Some Indications of Medicare/Medicaid Fraud?
Medicare and Medicaid fraud are committed with criminal intent. One indication of fraud is if the billing is not clear or if there are vague explanations for treatments provided. If the provider bundles all services into one large bill without breaking down the components, this can also point to fraud.
Healthcare providers committing fraud will try to bill the maximum possible per patient, which can lead to more treatments than necessary. Signs can include ordering unnecessary X-rays, choosing experimental treatments, and opting for invasive procedures.
If the clinic regularly has patient bills that are higher than those of similar clinics, this is another sign of fraud.
Healthcare providers committing fraud often get kickbacks for referrals, so if you see a provider constantly referring patients to a single hospital or specialist, they may have a monetary incentive to do so.
What Evidence Can Be Gathered to Prove Medicare/Medicaid Fraud?
To prove that a provider has committed fraud, it is necessary to gather patient records, scheduling books, and other official paperwork. For fraudulent billing, interviews with patients who did not receive the treatments billed are important. In some instances, like with unbundling and upcoding fraud, expert testimony can help.
To prove a provider has received kickbacks for referrals, you need to show evidence of a quid pro quo or collusion between parties.
For misrepresenting fraud scams, you need patient records of service.
When Should You Contact an Attorney If You Suspect Medicare/Medicaid Fraud?
You should immediately contact an attorney if you suspect Medicare or Medicaid fraud. If the claim is successful against the provider, you may be eligible for compensation.
Should You Contact the Authorities or an Attorney First in the Case of Medicare/Medicaid Fraud?
It’s better to contact an experienced attorney before reaching out to the authorities to make a claim of fraud. It’s especially important to do so if you work in the healthcare sector to ensure that you are not at risk of violating the Health Insurance Portability and Accountability Act (HIPAA).
By turning to a lawyer experienced with the False Claims Act, you can also make sure you do not face retaliation by your employer for exposing fraud.
Contacting an attorney first also lets you know if you have a case you can prove.
Blowing the Whistle on Medicare/Medicaid Fraud
Mr. Shoemaker has over 22 years of experience as a trial attorney and is a partner in the law firm of Patten, Wornom, Hatten & Diamonstein, L.C. ("PWHD"), based in Virginia. He has had significant experience litigating False Claims Act cases. Mr. Shoemaker, his partners, and associates are available for representation nationwide, including the Virginia Beach, Hampton Roads, and Washington D.C. areas.
If you are aware of fraud committed against the federal government or a state government, we encourage you to contact Mr. Shoemaker through this website or call our office at 757-223-4580 today. One of our paralegals will review the facts of your case with you, and then Mr. Shoemaker will call you and discuss your case free of charge*.