Medicare Fraud, Medicaid Fraud and Medical Fraud

As we continue to discuss the different types of fraud, we will now cover Medicare Fraud, Medicaid Fraud and Medical Fraud. Violations of Medicare laws and the Medicare Fraud and Abuse Statute also constitute violations of the False Claims Act. Hospitals, nursing homes, doctors, home health care agencies, durable goods providers, pharmacies, and laboratories that seek and receive reimbursement for Medicare and Medicaid funds are Government contractors subject to the False Claims Act.

Healthcare workers and families of a nursing home or hospital patient should pay particular attention to the services provided. Not only can this improve the healthcare for patients and loved ones, but it also helps ensure that public Medicare and Medicaid monies are properly spent in accordance with the law and good medical practice so Medicare Fraud / Medicaid Fraud does not occur.

Medicare Fraud

Billing for services not rendered, misrepresenting the type of goods or services rendered, or misrepresenting the nature of the patient’s illness is medical fraud and can trigger liability under the False Claims Act. Likewise, failing to provide correct data on annual hospital or nursing home cost reports that must be provided to the Government will violate the law, if the errors were done knowingly or intentionally. In addition, hospitals and nursing homes that provide substandard care may also be in violation of the False Claims Act as well as Medicare fraud.

Pharmacy-related violations could include the following:

  1. Partially filling prescriptions, but charging as if a full prescription was provided.
  2. Providing kickbacks to a medical provider in order to induce the provider to prescribe certain drugs.
  3. Prescribing unneeded medications, drugs, or treatment that are not a medical necessity.
  4. Charging Medicare or Medicaid patients a higher rate than others for the same prescription.
  5. Knowingly providing defective products or services.
  6. Falsely diagnosing a more severe ailment than the one the patient actually has known as “upcoding” a diagnosis, thereby justifying a more expensive drug therapy or other treatment than that which the patient’s health really requires.
  7. Inappropriate changes in patients’ prescriptions from one drug to another as a result of kickbacks or for other improper reasons.
  8. Falsely reporting drug research grant information to government agencies.

Our firm is only investigating claims in which a business entity, such as a company or medical practice, is submitting false claims to a governmental entity in excess of $500,000. We do not handle cases involving individuals receiving government benefits under false pretenses. (For example, we do not handle claims in which a person falsely claims disability in order to receive government benefits. ) For these claims, you should contact the appropriate governmental agency directly, such as a state medicare-fraud hotline, and report the fraud. Regarding tax fraud, we are only handling cases in which the underpayment of taxes exceeds $2 Million, and the income of the person committing tax fraud exceeds $200,000 per year.