Case EvaluationSpeak to a Whistleblower
Types of Fraud
Top 10 False Claims Cases in 2010
- Allergan - $600 million
- AstraZeneca - $520 million
- Novartis Pharmaceuticals - $422.5 million
- Forest Laboratories - $313 million
- Elan Corporation - $203.5 million
- Teva Pharmaceuticals - $169 million
- WellCare Health Plans - $137.5 million
- Mylan, AstraZeneca & Ortho-McNeil - $124 million
- Omnicare & IVAX Pharmaceuticals - $112 million
- Health Alliance of Greater Cincinnati - $108 million
Medicare and Medicaid
Whistleblowers in the healthcare industry regularly see companies submit false claims to Medicare or Medicaid for pharmaceutical drugs, medical supplies, services and equipment. These improper charges have cost our government billions of dollars, which is passed on to us as taxpayers.
If you work in or around the healthcare industry, be on the lookout for anyone who may be defrauding the government, as these types of False Claims cases have resulted in some of the biggest rewards for whistleblowers. Since there are numerous ways that people or companies can cheat Medicare and Medicaid, we have listed some examples below so that you can know what to look for.
Services not delivered or added on to bills
One of the simplest forms of health care fraud occurs when providers bill Medicare or Medicaid for services that are never given to patients. These schemes are so varied they can involve charging for virtually any procedure, medical supply or treatment in the field of medicine, but often center around diagnostic testing or services. These charges are usually added onto a bill with other legitimate charges, or records are falsified to substantiate the charge.
Up-coding and Unbundling/Fragmentation
Up-coding fraud occurs when a provider changes the code which is used to bill Medicare or Medicaid for a particular medical service to reflect that a more serious, and therefore more expensive, procedure was performed. The provider may also designate a more severe diagnosis than what exists in order to justify the up-charged procedure
Another way facilities overcharge with coding is through a practice known as “unbundling" or "fragmentation." This occurs when, instead of billing Medicare or Medicaid for a group of procedures, which creates a lower rate, a provider separates the billing for the procedures in order to charge an overall higher amount.
Treatment not Medically Necessary
Doctors or providers sometimes prescribe procedures or drug treatments not because they are necessary but rather because they have an arrangement with a vendor to receive some kind of kickback or benefit by doing so. Billing Medicare and Medicaid for drugs, services or procedures that are not medically necessary is fraudulent under the False Claims act and filing a lawsuit for such activity could secure you a significant award as a whistleblower.
Fraudulent Cost Reports
Hospitals and other facilities regularly submit cost reports to Medicare which are used to determine how much the government will reimburse them for major expenses such as building improvements and updated medical equipment. For some large providers, these cost reports can lead to billions of dollars in reimbursement. Any facility that inflates their costs or the number of Medicare patients they treat is subject to a whistleblower lawsuit under the False Claims Act.