Health care fraud
Encyclopedia
Health Care Fraud includes health insurance fraud, drug fraud
, and medical fraud
.
Health insurance fraud occurs when a company or an individual defrauds an insurer or government health care program, such as Medicare (United States)
or equivalent State programs. The manner in which this is done varies, and persons engaging in fraud are always seeking new ways to circumvent the law. Damages from fraud can be recovered by use of the False Claims Act
, most commonly under the qui tam
provisions which rewards an individual for being a "whistleblower
", or relator (law)
.
Over the course of FY 2010, whistleblowers were paid a total of $307,620,401.00 for their part in bringing the cases forward.
.
while only giving the patient a manual wheelchair.
People engaging in this type of fraud are also subject to the federal Anti-Kickback statute.
The case United States et al., ex rel. Jim Conrad and Constance Conrad v. Forest Pharmaceuticals, Inc, et al., No. 02-cv-11738-NG (D. Mass.) involved a drug manufacturer selling a drug, Levothroid, that had never been approved by the FDA. These allegations settled for $42.5 million due to multiple whistleblowers stepping forward to provide detailed information on the alleged fraud. The collective reward to the relators in this case was over $14.6 million.
If, however, they want to ensure the government actively investigates the alleged fraud, they are encouraged to contact legal counsel from an experienced firm that specializes in qui tam
litigation under the False Claims Act
. A good legal team can advise potential whistleblower
s of their rights, protections, and what evidence is necessary to solidify a case against the group leading the fraud.
Drug fraud
Drug fraud is a type of fraud in which drugs, legal or illegal, are cut or altered in such a way that diminishes their value below that which they are sold for.- Illegal drug fraud :...
, and medical fraud
Quackery
Quackery is a derogatory term used to describe the promotion of unproven or fraudulent medical practices. Random House Dictionary describes a "quack" as a "fraudulent or ignorant pretender to medical skill" or "a person who pretends, professionally or publicly, to have skill, knowledge, or...
.
Health insurance fraud occurs when a company or an individual defrauds an insurer or government health care program, such as Medicare (United States)
Medicare (United States)
Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...
or equivalent State programs. The manner in which this is done varies, and persons engaging in fraud are always seeking new ways to circumvent the law. Damages from fraud can be recovered by use of the False Claims Act
False Claims Act
The False Claims Act is an American federal law that imposes liability on persons and companies who defraud governmental programs. The law includes a "qui tam" provision that allows people who are not affiliated with the government to file actions on behalf of the government...
, most commonly under the qui tam
Qui tam
In common law, a writ of qui tam is a writ whereby a private individual who assists a prosecution can receive all or part of any penalty imposed...
provisions which rewards an individual for being a "whistleblower
Whistleblower
A whistleblower is a person who tells the public or someone in authority about alleged dishonest or illegal activities occurring in a government department, a public or private organization, or a company...
", or relator (law)
Relator (law)
-Qui Tam action:A Qui Tam Action may be brought by any party against an entity that is fraudulently collecting money from the United States government by filing false claims. The party bringing the suit -- the relator -- must have possession of information substantiating the claim of fraud against...
.
Recent News and Statistics
The FBI estimates that Health Care Fraud costs American tax payers $60 billion a year. Of this amount $2.5 billion was recovered through False Claims Act cases in FY 2010. Most of these cases were filed under qui tam provisions.Over the course of FY 2010, whistleblowers were paid a total of $307,620,401.00 for their part in bringing the cases forward.
Types of Fraud
There are several different schemes used to defraud the Health care systemHealth care system
A health care system is the organization of people, institutions, and resources to deliver health care services to meet the health needs of target populations....
.
- Billing for services not rendered
- Upcoding of services
- Upcoding of items
- Duplicate claims
- Unbundling
- Excessive services
- Unnecessary services
- Kickbacks
Billing for services not rendered
Often done as a way of billing Medicare for things that never happened. This can involve forging the signature of those enrolled in Medicare, and the use of bribes or "kickbacks" to corrupt medical professionals.Upcoding of services
Billing Medicare programs for services that are more costly than the actual procedure that was done.Upcoding of Items
Similar to upcoding of services, but involving the use of medical equipment. An example is billing Medicare for a power-assisted wheelchairWheelchair
A wheelchair is a chair with wheels, designed to be a replacement for walking. The device comes in variations where it is propelled by motors or by the seated occupant turning the rear wheels by hand. Often there are handles behind the seat for someone else to do the pushing...
while only giving the patient a manual wheelchair.
Duplicate Claims
In this case a provider does not submit the exact same bill, but changes some small portion like the date in order to charge Medicare twice for the same service rendered. Rather than a single claim being filed twice, the same service is billed two times in an attempt to be paid twice.Unbundling
Bills for a particular service are submitted in piecemeal, that appear to be staggered out over time. These services would normally cost less when bundled together, but by manipulating the claim, a higher charge is billed to Medicare resulting in a higher pay out to the party committing the fraud.Excessive Services
Occurs when Medicare is billed for something greater than what the level of actual care requires. This can include medical related equipment as well as services.Unnecessary Services
Unlike excessive services, this fraudulent scheme occurs when claims are filed for care that in no way applies to the condition of a patient, such as an echo cardiogram billed for a patient with a sprained ankle.Kickbacks
Kickbacks are rewards such as cash, jewelry, free vacations, corporate sponsored retreats, or other lavish gifts used to entice medical professionals into using specific medical services. This could be a small cash kickback for the use of an MRI when not required, or a lavish doctor/patient retreat that is funded by a pharmaceutical company to entice the prescription and use of a particular drug.People engaging in this type of fraud are also subject to the federal Anti-Kickback statute.
Examples of Fraud Cases
In the case United States ex rel. Donigian v. St. Jude Medical, Inc., No. 06-CA-11166-DPW (D. Mass.) St. Jude Medical, Inc. agreed to pay $16 million to quiet allegations of paying kickbacks to physicians. The whistleblower was able to provide detailed insider information as to the nature of the kickbacks, which ranged from entertainment to sporting event tickets and other gifts. The relator in this case was awarded $2.64 million.The case United States et al., ex rel. Jim Conrad and Constance Conrad v. Forest Pharmaceuticals, Inc, et al., No. 02-cv-11738-NG (D. Mass.) involved a drug manufacturer selling a drug, Levothroid, that had never been approved by the FDA. These allegations settled for $42.5 million due to multiple whistleblowers stepping forward to provide detailed information on the alleged fraud. The collective reward to the relators in this case was over $14.6 million.
Reporting Fraud
There are many ways to report cases of fraud. If a patient or health care provider believes they have witnessed Health Care Fraud, they are encouraged to contact the FBI via either their local office, telephone, or the online tips form.If, however, they want to ensure the government actively investigates the alleged fraud, they are encouraged to contact legal counsel from an experienced firm that specializes in qui tam
Qui tam
In common law, a writ of qui tam is a writ whereby a private individual who assists a prosecution can receive all or part of any penalty imposed...
litigation under the False Claims Act
False Claims Act
The False Claims Act is an American federal law that imposes liability on persons and companies who defraud governmental programs. The law includes a "qui tam" provision that allows people who are not affiliated with the government to file actions on behalf of the government...
. A good legal team can advise potential whistleblower
Whistleblower
A whistleblower is a person who tells the public or someone in authority about alleged dishonest or illegal activities occurring in a government department, a public or private organization, or a company...
s of their rights, protections, and what evidence is necessary to solidify a case against the group leading the fraud.