MEDICAID AND MEDICARE FRAUD

There are huge rewards for exposing fraud against Medicaid, Medicare or TRICARE.

If you are aware of a hospital, doctor, clinic, nursing home, pharmacy, pharmaceutical company, or any other type of company defrauding Medicaid, Medicare or Tricare, you may be able file a claim to recover triple the amount defrauded, plus civil penalties of up to $11,000 per false claim or bill submitted to Medicaid, Medicare or TRICARE.

If you do, you may get to keep between 15% and 30% of any monies recovered by the government, as a reward.

Providers of medical services, medical supplies and/or medical equipment often engage in a wide variety of fraudulent practices.  Some of the most common fraudulent practices include, but are not limited to, the following:

Unwarranted Billings - Billing for services which were not reasonable or necessary, in frequency, duration, or at all. Billing for medically unnecessary tests. Automatically running a lab test whenever the results of some other test fall within a certain range, even though the second test was not specifically requested.

Double Billing - Charging more than once for the same goods or service.

Upcoding Diagnoses - Inflating bills by using diagnosis billing codes that suggest a more expensive illness or treatment.

Upcoding Employee Work - Billing at doctor rates for work that was actually performed by a nurse or resident intern.

Upcoding Services/Goods - Billing for a more highly reimbursed service or product than the one provided.

Signature Fraud - Forging physician’’s signatures when such signatures are required for reimbursement from Medicare or Medicaid.

Unapproved Billing - Filing claims for reimbursement of expenses and for services while knowing that such reimbursements and services were not covered by Medicaid or Medicare. Billing for unlicensed or unapproved drugs or devices.

Phantom Billing - Billing for tests, goods and services that were never delivered or rendered.

Phantom Labor - Charging for employees that were not actually on the job, or billing for made-up hours to maximize reimbursements.

Bundling - Billing more for a panel of tests when a single test was asked for.

Unbundling - Using multiple billing codes instead of one billing code for a drug panel test in order to increase remuneration.

Concealment - Failing to disclose, or taking affirmative acts to conceal billing errors which resulted in overpayment for services or goods provided.

Equipment Billing Fraud - Billing for the use of new equipment, or premium equipment, when either used or inferior equipment is provided.

Billing for Brand - Billing for brand name drugs when generic drugs are actually provided.

Shorting - Charging for full quantities of prescriptions, when actually dispensing partial or short prescriptions.

Kickback Fraud - Prescribing a medicine or recommending a type of treatment or diagnosis regimen in order to win kickbacks from hospitals, labs or pharmaceutical companies.

Inflated Management Fees - Artificially inflating management fees in situations where the government pays management fees in connection with any provision of medical services, or in the conduct of government-sponsored medical research.

Shelling - Setting up a shell company, or manipulating the mode or receiving payments for the purpose of inflating the rate of reimbursement to be received.

Marketing The Spread - Where the manufacturer of a drug or medical device provides a false inflated price for their product to the government, and then actually sells their product at a lower price to hospitals, clinics and/or doctors.

This enables the hospitals, clinics and doctors to pocket the difference (known as “the spread”) between what the manufacturer charged them for the sale of the drug or device, and the higher amount which the government reimbursed the hospital, clinic or doctor for the drug or device.

Manufacturers can also defraud the government and market the spread, by providing rebates or substantial “free samples” of their drug or product to providers of medical services, thereby reducing the net price which the medical provider paid for the drugs or device, again enabling them to keep the difference between what they paid, and the amount of the reimbursement which they receive from Medicare, Medicaid or TRICARE.

To report these, or any other types of fraud against Medicaid, Medicare or TRICARE, call us at (516) 746-1600