Medicare and Insurance Fraud
What activities are considered healthcare fraud
Healthcare employers and healthcare whistleblowers are always on the lookout for these types of activities that could result in Medicare or Insurance fraud:
Paying for Patient Referrals –
Companies and individuals that pay others to refer over patients, such as insurance brokers getting paid by healthcare providers, or a lab or diagnostics business paying a physician to send patients for testing, or certain physicians getting paid more by a hospital because they refer them patients. Healthcare employers and healthcare whistleblowers are on the lookout for payment for patient referrals.
Billing for services that are not medically necessary -
Medically unnecessary services may include unnecessary inpatient admissions, advanced imaging, unnecessary tests or lab work, and other procedures. For example: the ordering of extra services that were never necessary and unrelated to the actual real reason why the patient came to see the physician. Healthcare employers and healthcare whistleblowers are on the lookout for unnecessary billing that increases in revenue dollars involving Medicare or insurance providers.
Billing for unlicensed personnel -
This may include services provided by individuals who lack the skills or proper licenses, or services provided by trainees without the required supervision. For example: if a physician has a technician perform the services, and the business bills the insurance company as if the physician had performed the service. Healthcare employers and healthcare whistleblowers are on the lookout for services performed by unlicensed and unsupervised personnel that generate extra revenue dollars through Medicare or insurance reimbursements.
Billing for unauthorized locations -
This may include services performed at a facility that is inappropriate for that service, or a facility that is improperly staffed or equipped for the procedure. Or for example hospitals systems that bill for services at the higher hospital rates, even though the services were provided outside of the hospital. Healthcare employers and healthcare whistleblowers are on the lookout for unauthorized locations that are used to increase revenue dollars received from Medicare or insurance providers.
Electronic health record (EHR) fraud -
Companies that gather and sell electronic health records systems and services may face liability for creating systems that fail to meet government certification standards. In addition, providers and hospitals may face liability for fraudulently claiming EHR incentive payments, or for submitting fraudulent bills based on EHR systems designed to improperly increase reimbursements. EHR marketing may also implicate unlawful kickbacks and other improper financial relationships. Healthcare employers and healthcare whistleblowers are on the lookout for electronic healthcare record fraud.
Healthcare Leases or Free Space - Real Estate -
Giving or receiving leased space from a hospital, clinic or lab, for free. When the incentive for providing the free space is the amount of referrals the other business provides. For example allowing an outside surgeon to setup an office inside a hospital for free or at a very discounted rate, when in reality it is being done because of the volume or value of referrals. Similarly, a lab company that gives free space to a doctor because they expect referrals back from the doctor. Healthcare employers and healthcare whistleblowers are on the lookout for free benefits of space provided in exchange for referrals or increase in revenue dollars
Off-label marketing of prescription drugs -
“Off-label marketing” means that a drug is promoted for a use that was not approved by the FDA, such as marketing a drug designed for adults to be used by children. Another example is recommending a higher dosage than is approved. Healthcare employers and healthcare whistleblowers are on the lookout for drugs being marketed for off-label use to increase in revenue dollars for the drug companies.
Discount/rebate and other pricing fraud -
Government healthcare programs pay for pharmaceuticals and devices at specified rates, often tied to specified cost metrics. Misuse or manipulation of these programs can result in the submission of false claims. Healthcare employers and healthcare whistleblowers are on the lookout for improper discounts and rebates that increase revenue dollars for device manufacturers and pharmaceuticals often reimbursed by Medicare or insurance companies.
Clinical trial/FDA fraud -
The FDA relies on trial data to verify the safety and efficacy of drugs. If any party in the trial process misrepresents, omits, or falsifies the data, such FDA fraud can create far-reaching damage to future users of the drug. Healthcare employers and healthcare whistleblowers are on the lookout for falsification of trial data that increase revenue dollars for the provider.
Compounding pharmacy fraud -
This fraud involves pharmacists mixing drugs or making large batches, rather than following strict procedures to meet the needs of individual patients. Healthcare employers and healthcare whistleblowers are on the lookout for unnecessary of compounding of pharmaceutical drugs that increase revenue dollars for the pharmacies.
Remember you cannot win an Award unless you file a Lawsuit.
If you think you have a situation that you would like to discuss with an attorney in confidence, do not hesitate to contact me directly Ben A. S. Mirza, Cell/Text 954-445-5503 or email me at [email protected]. We are a team of lawyers ready and standing by to correct the wrong, and we will do our best to earn you an award. We only make money if you get an award from the government. The right team of attorneys can make all the difference. We stand by to earn your business.