False Certifications and Information
This type of fraud occurs when health care providers submit claims containing false statements.
Example: Health care provider employees forge doctor signatures on reports in order to make claims.
Fraudulent Cost Reports
Medicare uses cost reports to determine an amount in reimbursements it should give a health care provider. Providers who purposely inflate their costs or give a false percentage of their services dedicated to Medicare patients are liable under the False Claims Act.
Example: Managers disguise personal expenses as Medicare billings and add them to cost reports.
Grant or Program Fraud
Grant or program fraud occurs when groups receiving government funds for research or special projects make false claims regarding their credentials, research, or projected research costs.
Example: A doctor applies for a grant under false qualifications, or the basis of the actual research performed under a grant does not meet the quality standards laid out by the grant.
Kickbacks
Kickbacks involve secret financial agreements between health care providers where one provider will provide some material benefit to another in exchange for prescribing or using their products or services. In cases where a kickback results in the government paying for medically unnecessary services or being overcharged, a false claim can also occur.
Example: A company gives physicians income guarantees, office-rent subsidies, low-interest/no-interest loans, loan forgiveness, or provides staff support in exchange for referrals by the physicians to their company.
Lack of Medical Necessity
This type of fraud occurs when health care providers bill Medicare and Medicaid for services or procedures that are not medically necessary.
Example: A doctor bills Medicare for X-rays and other tests regardless of whether or not the patient needed the procedures.
Services Not Rendered
The most common health care fraud is when health care providers bill Medicare or Medicaid for services that were never performed.
Example: A physical therapist bills for a session he never performed, a hospital bills for medical supplies it never ordered or received, or a doctor bills an extra hour for every
patient he sees.
Upcoding
When billing for Medicare or Medicaid, doctors and hospitals use numerical codes for their services. Each code represents a different reimbursement amount. Using a higher code than the service warrants is a common way to defraud the government.
Example: Medicare will pay more for an X-ray if it is used to detect a tumor or disease than if it is used for a routine check-up. Dishonest health providers will sometimes upcode their routine X-rays to get more money from the government.
Unbundling or Fragmentation
Medicare and Medicaid offer discount incentives for groups of procedures that are often performed together. To increase the reimbursement amounts, doctors and hospitals will unbundle the groups of procedures and bill for them individually.
- Example: A hospital bills 200 blood tests individually to Medicaid when the hospital is already receiving a reimbursement for the whole group of tests.
If you have been witness to these or any other activities that could be considered illegal under the False Claims Act, contact Halunen & Associates.
