Since the False Claims Act was amended in 1986, fraud in the healthcare industry has been the primary target of FCA whistleblowers. While the Government spends billions of dollars on the Medicare and Medicaid programs and healthcare costs continue to grow, healthcare fraud continues to be a major burden on the taxpayer. The Government Accountability Office (“GAO”) estimates that in FY2013 alone, Medicare lost $50 billion and Medicaid lost $20 billion because of improper payments to healthcare providers and entities. Every sector of the healthcare industry has been affected by fraud. Hospitals, physician practices, nursing homes, pharmaceutical companies, clinical laboratories, and medical device companies have all been held liable for defrauding federal healthcare programs.
The whistleblower provisions of the federal False Claims Act have been extremely effective in recovering taxpayer dollars lost to fraud in the healthcare industry, with more than $12.1 billion since 2009.
Major types of fraud in the healthcare industry include:
- Upcoding – billing federal healthcare programs for more expensive services than those actually performed by using a code with a higher reimbursement.
- Unbundling – billing federal healthcare programs separately for procedures that are required to be billed together. (link to larger page on improper billing and coding practices)
Inflated Cost Reports – submitting inflated annual cost reports to CMS to obtain a higher level of reimbursement for services performed on Medicare/Medicaid patients.
Billing for Medically Unnecessary Services or Services Not Rendered - billing federal healthcare programs for services that are not based on the particular medical needs of a patient.
Kickbacks for Referrals – healthcare entities commit this type of fraud when they knowingly offer or receive payment or remuneration in exchange for a federal healthcare program referral (link to separate AKS page)
Improper Self-Referrals - physicians commit this type of fraud when they make federal healthcare program referrals to an entity they have a financial relationship with. (link to separate Stark page)
Off-Label Marketing– drug and medical device companies commit this type of fraud when they market drugs or devices for uses not approved by the FDA. (link to separate page)
Best Price Fraud—drug companies commit this fraud by misrepresenting “the best price” of their drugs to the Medicaid program. (link to separate page)
Our whistleblower team includes attorneys who have handled healthcare fraud cases on behalf of whistleblowers, prosecuted fraud cases on behalf of the United States, and actually worked in the health care industry.
If you would like to speak to one of our attorneys about a potential whistleblower matter, please email us at firstname.lastname@example.org or call us at (610) 667-7706. All case evaluations are confidential and free.