There are many types of Medicare whistleblower cases where fraud can potentially exist.
Looking for more information about Medicare whistleblower cases? Medicare is a special government program where Americans aged 65 years and older receive health insurance benefits that the federal government pays for. The government uses insurance companies to help administer and process these benefits and pays for Medicare with taxpayer dollars.
With the aging baby boomer population, millions of individuals are using Medicare benefits. With such widespread use comes the opportunity for fraud. However, some forms of fraud occur more often than others. We’ll discuss some of these more common types of fraud that often lead to a whistleblower lawsuit and qui tam action.
Accepting or Offering Kickbacks
Kickbacks occur when someone offers or accepts money for improperly diverting or creating business that wouldn’t otherwise exist. For example, a clinic that pays a primary care physician $100 for each Medicare-eligible patient the doctor sends to the clinic could be an example of a kickback. The clinic offers the kickback of $100 and the primary care physician accepts the kickback.
In some situations, kickbacks can be more harmful than just stealing money from the federal government. If a doctor orders a medical procedure the patient does not need because it will give the doctor a kickback from the hospital or clinic providing the procedure, it can put the patient’s health at risk.
Billing the Federal Government for Nonexistent Services
False billing is another common form of Medicare fraud. Basically, the doctor or medical provider will bill the federal government for a medical service that never takes place. An example might include sending a bill for Medicare reimbursement for doctor’s visit that never happened. Or it could include a piece of medical equipment the patient doesn’t use. Instead, the doctor keeps the medical equipment and sells it under the table for cash.
Unless the Medicare reviewer is at the doctor’s office to see that the medical equipment actually goes into use or witnesses the doctor examine ten patients on a particular day instead of eight (yet bills for 10), it can be tough to detect this type of fraud. It is a very profitable way for unsavory doctors and healthcare providers to line their pockets with cash.
Billing the Federal Government for Medical Services Not Needed
Billing the federal government for unnecessary medical care is a very popular tool for fraudsters. This is because it is very difficult for the government to detect. Why is this so? Think of it this way. How is a Medicare examiner sitting in an office in Washington, DC supposed to know if that MRI or x-ray was not medically necessary? All the official will have are copies of the patient’s medical records, such as written notes from the doctor. If the doctor is taking part in the fraud, the doctor will write anything to support the medical test or procedure that’s not really necessary.
For instance, the doctor may write into a medical record that the patient might suffer from a torn ligament and the MRI is necessary to confirm this suspicion. The MRI will provide the information needed to surgically repair the ligament if there really is a tear. What makes this type of fraud even harder to detect is that the patient may not even know the medical test or procedure isn’t necessary.
All the patient knows is that they went into the office for knee pain and the doctor tells them that they will receive an MRI to see what’s going on in the knee. Even if the doctor knows there is no ligament tear and there is no need for an MRI, there is usually no way for the patient to know this. If the patient doesn’t know, it’s unlikely that the Medicare examiner in Washington DC will know.
Prescription Medication Fraud
Prescription medication fraud can exist in many different ways. Examples include a doctor prescribing a medication that is unnecessary or for a higher than needed dosage. Furthermore, it could include a patient selling his or her prescription to someone else. A final example would be forging a doctor’s signature to get a certain medication.
The most common types of drugs subject to prescription medical fraud are painkillers, like opioids and opiates. So many people are addicted to these painkillers. Therefore, there is a massive financial incentive for patients and doctors to commit prescription medication fraud. This type of Medicare fraud is therefore partially responsible for the painkiller addiction epidemic currently ravaging the United States.
This type of fraud can be difficult to detect. That’s because the doctor or healthcare provider may not be in on it. With a single patient committing the fraud, it is probably less likely that there will be a whistleblower who can identify the fraud and report it to the federal government. Also, if a single patient is committing the fraud, there is usually less money at stake, so any reward by bringing a qui tam action will be relatively small. This means it’s unlikely someone will step up as a whistleblower and relator.
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