Dangerous Medicare and Medicaid Fraud Schemes

Every industry has opportunities for scams and fraud, and the medical industry is far from exempt. Even people within the industry or workplace may not realize when fraudulent practices are going on around them. Because fraud schemes typically originate near the top of an organization, people who keep the books, fill out the forms, or input the data into the computer may be totally oblivious. In all likelihood, they have no idea that they are helping to scam the government. Others may suspect something but are afraid to speak up for risk of putting their jobs in jeopardy.

In the medical industry, a common way to scam the government involves fraudulent billing of Medicare and Medicaid. There are a number of types of schemes used. A few of them are outlined here.

Phantom Billing. In phantom billing schemes, the medical provider may bill Medicare for procedures or medical tests that are never performed. They may also bill for procedures, medical tests, or equipment that weren’t really necessary.

Fake Patient Billing. In this practice, a patient works with the medical provider to scam the government. The patient gives his or her Medicare number and the medical provider bills for treatment never received or needed. Both the patient and the medical provider get kickbacks.

Upcoding: Upcoding occurs when a medical provider deliberately uses a higher-paying code on the claim form for a patient. This way they receive reimbursement for a more expensive procedure or device than the actual one.

Unbundling: Unbundling involves submitting bills separately to maximize reimbursement against Medicare policy. For example, certain panels of lab tests are performed together so frequently that they constitute a billing group of their own. Billing for each test separately would result in greater reimbursement and is unlawful.

Each fraudulent bill sent to Medicare is money cheated from US taxpayers. In order to catch these schemers, the country relies on whistleblowers. If you have information regarding false billing practices, you can step forward and potentially receive a sizeable reward under the Federal False Claims Act. If your information results in convictions and return of fraudulently-obtained money to the government, not only do you get a portion of the recovered funds, but every American taxpayer will be grateful for the relief. Honesty pays. Prevent fraud. If you do have information about potential billing scams, contact a lawyer who can review your case, advise you of your options, and ensure your rights are protected.