Medicare and Medicaid are programs of the federal government that provide medical insurance. Medicare provides insurance for people over the age of 65, and Medicaid provides medical insurance to people free or at a low cost to certain people based on their income and the size of their family. The rules regarding eligibility are different in different states. The funds for the program, however, come from the federal government.
Unfortunately, many people commit many different kinds of healthcare fraud in connection with Medicare and Medicaid, including the following:
- Billing for Services not Performed: For example, a doctor might bill Medicare or Medicaid for services that they did not actually provide to a patient. A lab might bill for an x-ray or lab test that was never done;
- Substitution of Generic Drugs: A pharmacy might substitute a generic drug for a brand name drug at a substantially lower cost but then bill Medicare, Medicaid, or an insurance carrier for the brand name drug and pocket the difference;
- Unbundling: Unbundling occurs when a provider takes one medical procedure and breaks it down so they can bill each of its component parts. An example of this would be a provider billing for a surgery and then billing again for a check-up appointment for the patient the following week;
- Unnecessary Services: A provider might falsify a patient’s diagnosis in order to collect payments for unnecessary lab tests;
- Double Billing: A provider bills both Medicaid or Medicare and another insurance carrier for the same service;
- Fraudulent Use of Another’s Medicare or Medicaid Number: A person might get the Medicare or Medicaid identification number of a person who is covered by either program and use it to obtain health care services or to submit fraudulent claims using the person’s number.
Fraud can take many forms in addition to the ones listed above.
Who Can Be Held Liable for Medicare and Medicaid Fraud?
First of all, it is important to know that the federal False Claims Act (FCA) authorizes the federal government to pay a reward of up to 30% to people who report Medicare and Medicaid fraud. So there is an incentive to report the fraud of which a person has knowledge.
In addition, there are federal laws that forbid retaliation against a person in their workplace if they report Medicare and Medicaid fraud to a federal or state agency. Many states have similar laws. If a person has personally observed Medicare fraud in their workplace, these federal laws may protect the person from retaliation for reporting the fraud, i;e. whistleblowing.
As for who can be liable for Medicare and Medicaid fraud, any person who commits fraud or participates in fraud in any way can be liable. This could include the following people:
- Medicare coders;
- Medical office billing specialists;
- Compliance officers;
- Emergency Medical Technicians;
- Paramedics;
- Physicians;
- Physicians Assistants;
- Nurses;
- Physical therapists;
- Medical office accountants.
I Am the Victim of Fraud. What Should I Do?
Recovering losses from Medicare or Medicaid fraud can be complicated and difficult. A health law attorney can advise a person on what steps to take to report the fraud and the remedies to which a person is entitled. If need be, a health law lawyer can also represent a person in court.
An experienced healthcare lawyer is familiar with the False Claims Act and federal laws that protect whistleblowers. A lawyer could make sure that a person who reports fraud that may be going on in their place of employment receives any reward of money to which they are entitled and that they are protected from retaliation in their place of employment if that is a risk.
If a person suspects that Medicare or Medicaid is being charged for a medical device or healthcare service that the person did not in fact receive, or if a person suspects that their Medicare or Medicaid card or number has been stolen, the person should contact one of the following:
- 1-800-MEDICARE (1-800-633-4227);
- The U.S. Department of Health & Human Services’ Office of the Inspector General.
Of course, often the victim of Medicare and Medicaid fraud is the federal government, which funds the two programs. It is the money of the programs that is essentially stolen through fraudulent claims and not the assets of any individual. This is why the federal government offers a reward to people who report fraud.
It is important to note that a person cannot receive a money reward for calling a Medicare hotline. A lawyer must represent a person to be eligible to receive a reward. In addition, the fraud must be of a large scale. For example, it may involve a hospital or a large medical practice that is cheating through many people and doing it repeatedly.
A person’s lawyer files what is referred to as a qui tam application under the False Claims Act.
Most lawyers who represent people in qui tam actions charge a contingency fee, meaning they get a percentage of any money reward given to their client.
To win a reward for reporting Medicare or Medicaid fraud, a person must share information that reveals a large fraudulent scheme and not just a single or isolated instance of fraud. The amount of the reward depends on how much money the government is able to recover from the person or entity that has stolen government funds through their fraudulent scheme.
According to experts in this type of action, the whistleblowers who have received the largest rewards were those who worked for a large hospital or healthcare provider who perpetrated fraud repeatedly on a large scale. Of course, they gained knowledge of the fraudulent scheme in the course of their employment. They may actually be able to get the reward even if they had been asked to participate in the fraudulent scheme.
The federal government pays the largest monetary rewards when the whistleblower has information that only an insider can gain that proves the Medicare or Medicaid fraud.
If another individual uses a person’s personal information, including their Medicare or Medicaid identification number, to commit Medicare fraud or other crimes, this could amount to the crime of identity theft. A person should protect their Medicare and Medicaid information in the same way that they protect their credit card and Social Security number.
However, if their information is used fraudulently, they can report the theft to the Federal Trade Commission and follow other steps as recommended by the Federal Department of Justice on its website.
What Should I Do if I Have Been Accused of Medicare/Medicaid Fraud?
If you are aware of ongoing Medicare or Medicaid fraud and would like to report it, you must consult an experienced healthcare lawyer first. LegalMatch.com can connect you with a lawyer who can make sure that you receive the full amount of any reward to which you are entitled. In addition, your lawyer may be able to protect you from retaliation if that is a risk at your place of employment.
If you have been the victim of identity theft and someone has used your Medicare or Medicaid number or other information to commit theft, your lawyer can advise you of the steps you need to take to protect yourself and recover any losses.
