What Is Medicare/Medicaid Fraud?
Medicare Fraud and Medicaid Fraud mean a health care provider – i.e., a pharmaceutical company (or Big Pharma), doctor, dentist, hospital, hospice care provider or nursing home – makes or causes a fraudulent reimbursement to claim to Medicare, Medicaid or other government health program such as Tricare. Medicaid and Medicare whistleblower rewards are available for those who report fraud under the qui tam provisions of the False Claims Act.
The most common types of Medicare fraud or Medicaid fraud include:
- Payments of kickbacks to induce providers to prescribe products or prescriptions;
- Billing for unnecessary procedures or procedures not performed;
- Billing for unnecessary medical tests or tests never performed;
- Billing for unnecessary equipment;
- Upcoding to overcharge for services or products; and
- Off-label drug marketing of prescriptions, devices, or equipment.
Once the government receives a complaint under the qui tam provisions of the False Claims Act, it is obligated to investigate the underlying health care fraud allegations.
Can I file a qui tam claim on medicare fraud?
Yes. The federal government is extremely concerned about Medicare and Medicaid fraud and has consistently made going after Medicare and Medicaid fraudsters a top priority. Whistleblowers who bring Medicare and Medicaid fraud to the attention of the government under the False Claims Act qui tam provisions have consistently recovered some of the most substantial whistleblower rewards paid out by the government.
How are Medicaid and Medicare whistleblower rewards paid?
Qui tam relators (whistleblowers) are paid directly by the government from the recoveries obtained from successful False Claims Act lawsuits. There are several ways the litigation can lead to a reward. After the Medicare whistleblower formally files a qui tam complaint, the government must investigate the underlying Medicaid fraud or Medicare fraud allegations, and, based on the results of that investigation and other factors; the government can intervene and become the lead plaintiff in the case. Significantly, the False Claims Act imposes treble damages against the defendant. In other words, a defendant must pay to the government $3 for every $1 obtained as a result of the fraud, plus an additional penalty of $5,500 to $11,000 for each time a claim was submitted. The qui tam whistleblower ultimately is paid by the federal government a reward of at least 15% of the entire recovery (treble damages plus penalties) but not more than 25%.
What if the government doesn’t take my case?
If the government does not intervene in a False Claims Act lawsuit, the qui tam Medicare whistleblower can dismiss the case and end the litigation or choose to go forward with the case without support from the government. If the government does not intervene, then the reward paid to the qui tam whistleblower increases to not less than 25% and not more than 30%, plus legal fees and costs.
How large are Medicaid and Medicare whistleblower rewards?
Medicare and Medicaid fraud claims can be extremely large. For example, multiple whistleblowers filed separate False Claims Act qui tam lawsuits against Bristol Myers Squibb Co. alleging the company paid kickbacks to doctors to induce the submission of false claims to Medicare and Medicaid for Bristol Myers’ pharmaceutical products. Kohn, Kohn, and Colapinto represented the Bristol Myers sales agent, who received the largest individual whistleblower share of the more than $500 million recovered by the government. In another case, multiple whistleblowers filed False Claims Act complaints against GlaxoSmithKline alleging Medicare and Medicaid fraud case, the government intervened and collected $333 million and paid the whistleblowers $53 million.
If you know of improper Medicare and Medicaid billing practices and are concerned that fraud against the government has or may be occurring, you should contact a whistleblower attorney to help evaluate the information you have. Seeking out assistance from a knowledgeable False Claims Act law firm may be the best way you can protect yourself and ultimately obtain a reward for the aid you provide the government in ending the Medicare fraud, Medicaid fraud, or Tricare fraud.
How can I report and receive Medicaid or Medicare whistleblower rewards?
Several avenues allow a whistleblower to report Medicare fraud and Medicaid fraud, but there is only one way to receive a reward for doing so. A whistleblower can report fraud internally to a hotline (which we highly recommend against), bring their concerns to the Health and Human Services Office of the Inspector General, as well as to members of Congress. However, these reports will not provide the whistleblower with a reward. The only way a Medicaid or Medicare whistleblower reward can be obtained, is via the False Claims Act qui tam provisions. KKC has developed expertise in this area and can help you file a successful reward claim.
What Is upcoding?
Upcoding is a type of fraud that service providers commit when they charge more for a service than it costs. Upcoding happens when service providers use different or higher CTP’s that are necessary. A CTP stands for Current Procedural Terminology, and it creates a code for to every conceivable medical procedure, and how much they will get reimbursed for it. An example of Upcoding is a doctor saw a patient for a regular check-up, CTP coded for a reimbursement of $60, but the doctor used the CTP for an extended check-up, which reimburses $100.
Medical procedures become bundled together when they are related or usually performed together, such as incisions and closures incidental to surgeries, and Medicare/Medicaid has lower reimbursements for these procedures when combined than when performed separately. Unbundling is another type of fraud that occurs when service providers charge separately for such procedures, thus increasing their Medicare/Medicaid reimbursements.