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MEDICAID FRAUD ATTORNEYS BLOG

 

This site provides information and commentaries to everyday people and attorneys alike.  Medicaid Fraud topics ranging from going to jail for Medicaid fraud to winning huge rewards for reporting it will be discussed. To begin with, what exactly is Medicaid Fraud and what types of individuals and businesses commit it?

 

 

MEDICAID FRAUD

There are many devious ways in which individuals and businesses may scheme to defraud Medicaid, and even as you read this someone is probably devising a new one. Here are just a few of the ways that providers defraud Medicaid, according to the Office of the Medicaid Inspector General;

  • Billing for unnecessary services – Ordering and then subsequently charging the Medicaid program for services a patient does not need;
  • “Phantom” billing – Billing Medicaid for services or for dispensing products that the patient never received, such as patient visits that never took place, dental fillings for teeth that had previously been extracted, medical equipment that was never delivered;
  • Multiple billing – Intentionally sending bills to Medicaid for the same procedure or office visit more than once;
  • Improper Upcoding – Intentionally billing Medicaid for a more expensive treatment or medication than the one the patient actually received;
  • Kickbacks – When Medicaid providers such as physicians, hospitals, dentists, clinics, etc., give money, items of value, or other considerations to other healthcare providers in exchange for referrals or for business; and
  • Selling drugs/forging or altering prescriptions – When a Medicaid patient fills a legitimately authorized prescription, written by an authorized physician, and then sells the contents for profit, that is fraud. Altering the amount of the prescription, or stealing a prescription pad from a doctor and then using is also fraud.

Let’s just go into an every day explanation that will make more sense to the people reading this who are not attorneys. We want people who are exposed to this type of fraud to be able to pick it out and be aware of their options!

 

PROVIDERS

Provider fraud is when a business or individual who accepts Medicaid commits fraud. Here is a list of different types of providers, though there may be others;

Doctors

Hospitals

Nursing Homes

Visiting Nurse Services

Home Healthcare Providers

Now let’s get into some examples of the types of fraud that may be committed by these providers.

Billing for Unnecessary Services – an example of this might be when you go to the doctor with a sore throat and he orders a blood test for high cholesterol, even though you have no indication of high cholesterol. Simply put, the provider is looking for excuses to “pad” their bill to Medicaid.

Phantom Billing – sometimes referred to as “Ghost Billing”, simply means that the providers, your doctor for example, sees you for a sprained ankle, and then bills Medicaid for other treatment you did not receive. The doctor may bill Medicaid for treating a broken wrist on the same visit, even though you didn’t break your wrist and didn’t receive any treatment for a broken wrist. Dentists who accept Medicaid can be notorious for this type of overbilling.

Multiple Billing and Upcoding are self explanatory – an example of multiple billing might be if a doctor or hospital saw you once and then billed Medicaid three times for the same visit. Upcoding is almost the same as billing for unnecessary services and ghost billing.

Kickbacks – this is a good one because “kickbacks” can be disguised in ingenious ways. For example, a pharmaceutical company pays for a vacation for a doctor in exchange for the doctor prescribing drugs the company sells.

Selling Drugs/ Forging Prescriptions – pretty much self explanatory.

 

 

RECIPIENT FRAUD

Recipient fraud can occur when an individual who applies for Medicaid falsifies their application by either omitting certain information, such as assets, ie. bank accounts, or by lying about the amount of income they have or assets they own. Medicaid fraud committed by recipients is not a high priority for investigators due to the lack of resources to investigate and prosecute these crimes. The Office of the Welfare Inspector General investigates recipient fraud in New YorkState, as well as local Medicaid Office investigators.

PUBLIC CORRUPTION AND MEDICAID FRAUD

Public corruption related to Medicaid fraud can occur when a worker employed by a local Medicaid Office, whose job it is to determine a person’s Medicaid eligibility, takes a bribe or receives a benefit for placing an individual on Medicaid who may not otherwise qualify. The law enforcement agency whose jurisdiction includes investigating public corruption is the F.B.I. These crimes may then be prosecuted by the U.S. ATTORNEYS OFFICE.

HOW CAN SOMEONE WIN A HUGE REWARD FOR REPORTING MEDICAID FRAUD?

Contrary to popular belief, the government pays very little reward money to individuals who report Medicaid fraud directly to their local authorities. The best way to report provider fraud is to first consult an attorney who specializes in Whistleblower Lawsuits. These may also be called Qui Tam Lawsuits. The attorneys who probably do best with these types of lawsuits are the ones that worked with the federal government prosecuting health care fraud. More information on how to find these attorneys, or former federal prosecutors, later.

HOW MUCH CAN YOU WIN IF YOUR CASE IS SUCCESSFUL?

The federal government can reward you up to 30% of the amount they recover from the fraud. Individuals and their attorneys often win several million dollars in these cases. This does not happen overnight. It can literally take years before you see a penny. Your lawyer will ask you for a third or more of your winnings, but the lawyer may also get an order from the court for the other side to pay all or part of his legal bill – on top of the percent the lawyer takes from your winnings. Later on we will list actual cases and the amounts awarded to the whistleblowers.

 

 

WHAT IS A QUI TAM LAWSUIT?

A Qui Tam lawsuit, also known as a Whistleblower lawsuit, in the simplest terms, is when an individual who has uncovered Medicaid / Medicare or other Welfare Fraud, sues the entity on behalf of the government. This is done under the False Claims Act. Your lawyer will submit your proof/information in the form of a lawsuit, to the proper government agencies. These include the F.B.I., the U.S. ATTORNEYS OFFICE, as well as state investigative agencies. The reason for this is your attorney hopes that you have provided enough credible evidence to prove Medicaid/Medicare Fraud, and that the government will intervene in your case.

 

WHAT DOES IT MEAN FOR YOU IF THE GOVERNMENT INTERVENES IN YOUR LAWSUIT?

When your attorney first files your lawsuit with the government, it is under “seal”. That means you are not allowed to talk about it until the government unseals your case. The reason for this is the government will review your lawyer’s submission and determine if it rises to the level of government intervention. The major factors considered by the U.S. Attorneys Office for intervening in your case are based on the dollar amount of the fraud, and the government’s chances of winning the case based on the evidence your lawyer has presented. The competition for government intervention in a Whistleblower Lawsuit is fierce! If the government intervenes in your case, it basically means they take over the investigation and prosecution of your claims. This is the best case scenario, and most lawyers who file a Qui Tam lawsuit on your behalf will have language in their retainer agreement that gives them to the option to drop your case if the government does not intervene.

WHAT GOES ON IN THE TIME THE CASE IS SEALED?

The government will review the case. If it looks like they have a good chance at making a huge recovery based on the amount of proof and the amount of the fraud in front of them, they may decide to pursue your claim. Once the government decides to go forward, they will open an investigation, usually calling in the F.B.I. to handle it.

 

WHAT HAPPENS WHEN THE F.B.I. INVESTIGATES YOUR CLAIMS?

The F.B.I. will go over your evidence and decide, along with the U.S. Attorneys Office, which angles to pursue. The F.B.I. will form an investigative strategy which may include the individual who filed the complaint participating in the investigation. You may be asked to wear a “wire”, a concealed recording device, and then to engage the people involved in the fraud in conversations, the goal of which is to record the alleged perpetrators making incriminating statements.

WHAT IS MEDICARE FRAUD?

Medicare fraud is similar to Medicaid fraud in that they are both Healthcare fraud which can be committed by providers such as doctors, hospitals and nursing homes. Medicare is a federally funded health care program which can supplement Medicaid. Medicare patients receive a statement each time they use their benefits in a doctor’s office or hospital. If the individual receiving the care checks that statement and sees charges for services they did not receive, there is a possibility that fraud has been committed. If there is a pattern of improper billing, the likelihood of fraud increases.

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