Efficient and Effective Legal Representation

How can you identify Medicare fraud?

On Behalf of | Jul 6, 2023 | Whistleblowing |

Millions of people depend on Medicare for financial support as they age. Unfortunately, some healthcare providers take advantage of this vital program for their own financial gain. Medicare fraud can take many different forms, and healthcare employees should know how to identify this illegal conduct.

10 examples of Medicare fraud

Medicare fraud can involve misrepresenting many aspects of a patient’s care to bring in additional profits. For each of the examples below, Whistleblowers have obtained multi-millions of dollars returned to the Taxpayers and a share for themselves. Fraud can include:

  • Phantom billing – Billing for services that a patient never received is a form of Medicare fraud. Examples of this fraud include billing for appointments the patient did not attend or tests they did not undergo.
  • Billing for medically unnecessary services – This can include conducting testing that is not even used for diagnostic or treatment purposes or providing unnecessary treatments
  • Double-billing — Double-billing occurs when a patient receives one service or item, but their healthcare provider charges Medicare multiple times.
  • Unbundling — This type of fraud occurs when medical services would usually be bundled together but a provider charges for those services separately.
  • Upcoding — When a provider bills Medicare for more costly or complicated services than they received, this is known as upcoding. This can take many forms, such as billing for individual physical therapy, while actually, the therapist is going between multiple patients at the same time.
  • Kickbacks — If a provider accepts money, gifts or other rewards from a supplier in exchange for prescribing their medications or medical devices, this is a form of fraud.
  • Stark Act referrals — if a provider refers you to a doctor or pharmacy or specialist or hospital with which the provider has a financial arrangement or receives kickbacks.
  • Fraud related to prescription drugs — Misconduct when providing medicine may be guilty of Medicare Part D fraud. One example would be when a pharmacy provides name-brand medication when a prescription specifies a less expensive generic drug.
  • Charging Medicare patients more – Some providers charge government plans more than private plans, although by law the government is to be given the lowest price offered to others.
  • Not Charging a Co-Pay — This is done to induce patients to get the service or the medicine anyway so the provider can charge the government for it.

Holding healthcare providers responsible for these and other fraudulent activities often depends on the willingness of employees to report fraud performed by their employer or coworkers. People who report may be eligible for a financial reward for providing this information which can sometimes be in the millions of dollars.

While justice often depends on those who come forward with information, it is also essential for these whistleblowers to protect themselves in the process. Experienced guidance can help whistleblowers hold healthcare providers responsible for fraud while protecting their rights and career.