MEDICARE WHISTLEBLOWER

Medicare whistleblower who knows about false billing claims or other fraud in the Medicare program can file a whistleblower lawsuit and potentially earn a huge reward when the government collects.

Our whistleblower attorneys have successfully represented clients in whistleblower matters across the United States. Our firm has offices in Atlanta GA, Alexandria VA, and Washington DC, and we frequently travel to other federal courts to help whistleblowers recover rewards.

Learn the 7 steps to a whistleblower reward

Medicare is not the only federal health care program where fraud occurs. Here are the six federal health care programs where false billing has been reported:

1. Medicare – the largest federal healthcare program provides healthcare insurance to all individuals over 65 years of age.
2. Medicaid – a federal health insurance program for over 74 million low-income Americans.
3. The Children’s Health Insurance Program (CHIP) – a federal program funding healthcare for children in low-income families.
4. TRICARE – administered by the Department of Defense, this program provides healthcare coverage for members of the military and their families.
5. Veteran’s Health Administration – this program operates hospitals and clinics across the country and provides healthcare services to military veterans.
6. The Indian Health Service – the federal agency responsible for providing healthcare to American Indians and Alaskan Natives.

Many of these programs work with private healthcare providers and hospitals who bill the federal government for reimbursement after treating patients. Given its size, most of the fraud that occurs in government-sponsored health care programs occurs in the Medicare program.

Anyone with knowledge of false billing or other fraud in the Medicare program by a pharmaceutical company, hospital, doctor, clinic, or other health care provider can report the fraud and potentially earn a huge award.

Wherever you work in the healthcare industry, it is important to be aware of the various ways in which individuals and organizations in the industry can defraud the government. Familiarity with the different federal healthcare programs and knowing the most common ways they are defrauded can help you identify a whistleblower claim.

Some of the most common areas of Medicare fraud are:

• Billing for Services Not Provided – This is a common type of healthcare fraud, and it occurs when a healthcare professional or organization bills a federal healthcare program for services never performed. This can include billing for diagnostic tests that were never performed, medical supplies not delivered, or billing for a physician’s time when only nurses provided treatment.
• Upcoding – When healthcare providers bill the government for services they claim to have provided patients, they use individual “codes” for each medical procedure. Each procedure has a different code, and there are different codes based on whether the procedure was performed by a doctor or another healthcare professional. Healthcare fraud involving “upcoding” involves using a billing code for a medical procedure that is more expensive than the procedure actually performed. For example, a doctor may perform a minor outpatient procedure but bill the government under a code for a major operation. It’s also not uncommon for this type of fraud to involve billing the government under a doctor’s code when the procedure in question was actually performed by a nurse.
• Unbundling –While each medical procedure has its own billing code, multiple drugs and procedures that are “bundled” together as part of one treatment have their own separate code. Performing knee surgery, administering anesthesia, and providing painkillers, for example, are all separate procedures with their own billing codes, but they are bundled together under one billing code when they are all part of a single knee operation. The federal government often requires that providers bundle procedures since bundled treatments are usually cheaper than billing for each part of the treatment separately. “Unbundling,” as you might expect, is when a healthcare provider intentionally bills the government using individual billing codes for drugs and procedures that were actually part of a single treatment. This is usually prohibited by federal healthcare programs, though some healthcare providers think it’s an easy way to defraud the government. The most common cases of “unbundling” include diagnostic testing panels that are billed for each individual test performed and post-operative care that is unbundled from the care provided in the initial surgery.
• Unnecessary Treatment – Federal healthcare programs and the laws that regulate them define certain medical treatments as “medically necessary” and limit reimbursements only to those types of treatments. Healthcare providers are therefore prohibited from falsifying diagnoses or billing for drugs and procedures that are below the legal standard of “medically necessity,” which may be a different standard than the healthcare provider’s personal or professional opinion. A healthcare provider can commit fraud by intentionally, or even recklessly, submitting a claim to the government for a procedure that is not “medically necessary,” as defined by federal regulations.
• Off-label Marketing – While the Food and Drug Administration approves drugs only for certain treatments and conditions, physicians often prescribe those drugs for uses that have not been approved by the FDA. Sometimes this is OK, especially when there is a legitimate medical need for the unapproved use of the drug. But even if there is a valid reason to prescribe the drug for an unapproved use, healthcare providers are strictly prohibited from advertising or otherwise marketing the drug for those unapproved uses. They are also prohibited from encouraging or influencing other healthcare providers to use those drugs for unapproved uses. Common cases of this type of healthcare fraud include pharmaceutical companies trying to persuade doctors to prescribe or endorse their drugs for unapproved uses in exchange for illegal kickbacks, and with no regard for patient safety.
• Inflated Drug Prices – The cost of prescription drugs has been rising with breakneck speed in recent years. While some level of inflation is to be expected, sometimes pharmaceutical companies illegally and artificially inflate the price of their drugs, since federal healthcare payments are based on a drug’s average wholesale price. Pharmaceutical fraud can occur on a massive scale, as the pharmaceutical industry is worth hundreds of billions of dollars. Consequently, a whistleblower that reports fraud by a drug manufacturer stands to receive a substantial reward if the government obtains a recovery. In one 2017 case alone the federal government recovered $465 million from a single drug manufacturer.
• Medicare Part D Fraud – Medicare Part D provides coverage for prescription medicines for individuals eligible for Medicare. The program also funds some pre-approved private insurance plans, which makes the program especially vulnerable to fraud.