Government Fraud

Medicare Fraud Lawyer

Do you have evidence of Medicare fraud? Do you work for a healthcare treatment facility that submits false claims to Medicare for reimbursement? The law firm of Hughes Ellzey, LLP can help you today. Medicare fraud and Medicaid fraud have cost the federal Government billions of dollars. Qui tam (whistleblower) lawsuits filed under the False Claims Act have been responsible for some of the Government’s biggest health care fraud recoveries. Whistleblower attorney W. Craft Hughes aggressively represents whistleblowers in claims to stop hospitals, physicians, and healthcare corporations from defrauding Medicare and the Government. Our lawyers will help you file a confidential claim relating to Military Fraud, Medicare Fraud, Healthcare Fraud, or other types of fraud against the Government.

If you need help and want a free legal consultation, please contact a Medicare fraud lawyer at Hughes Ellzey, LLP by calling toll-free 888-350-3931, or send us your contact information using our Contact Form. An attorney will call you as soon as possible after receiving your contact information.

The False Claims Act (“FCA”) is the United States Government’s primary tool for redressing fraud against the Government, including Medicare. If the Government intervenes in your claim, you are entitled to 15%-25% of the proceeds from the settlement. The deadline for filing a False Claims Act lawsuit can be as short as six years. If you plan to take action, it’s important you contact us as soon as possible.

There are many different ways companies and individuals can bilk Medicare and Medicaid. The examples of health care fraud that are discussed give an idea of the types of fraud that have been or could be the basis of qui tam lawsuits.

  • Kickbacks and improper payments to group purchasing organizations (GPOs);
  • Services not rendered/add-on services;
  • Upcoding and Unbundling/Fragmentation;
  • Kickbacks;
  • False Certifications and Information;
  • Lack of Medical Necessity;
  • Fraudulent Cost Reports; and
  • Grant or Program Fraud.

Kickbacks and Improper Payments to Group Purchasing Organizations

Kickbacks to group purchasing organizations (“GPOs”) are basis of Medicare fraud. The basis of the fraud is the improper payments or fees that vendors, manufacturers, distributors and suppliers make to GPOs to influence the hospital purchasing companies contracting decisions. The GPO contractors might make straight kickbacks to the GPO or pay kickbacks in another form, such as paying higher administrative fees to the GPO than are permissible under the ‘safe harbor’ provisions of the Anti-Kickback Statute. GPO contractors also might pay a marketing fee to the hospital purchasing companies as another form of a kickback.

A 2005 HHS OIG report, Review of Revenue from Vendors at Three Group Purchasing Organizations and their Members, found that (1) hospital members of GPOs didn’t fully account for GPO revenue distributions in their Medicare cost reports and (2) GPOs only distributed 69 percent of their net revenue to their hospital members, retaining 31% for themselves to provide reserves and venture capital for new business lines. GPO practices can violate both the federal False Claims Act and state false claims laws for Medicaid fraud. Under the False Claims Act, whistleblowers are entitled to 15% – 25% of the amount the Government recovers as a result of their qui tam lawsuits. If you are aware of improper payments being made to a GPO and would like to discuss your concerns with our attorneys, please contact us immediately.

Services Not Rendered/Add-On Services

Probably the clearest example of fraud by health care providers involves billing for services that were never delivered to patients. The basic scheme can involve as many variations as there are treatments.

For example, some physicians bill Medicare or Medicaid for diagnostic procedures they never performed, physical therapists bill for sessions that never took place, and nursing homes might bill for supplies that were never actually purchased or used. There is often some falsification of records to support improper billings.

Billing for unnecessary procedures or services that have been added to a bill for legitimate charges is another type of false claim. The Government also has held clinical laboratories liable when they induced physicians to order unnecessary add-on tests by including the extra test in a standard blood chemistry panel at minimal or no extra charge to the physician. The lab then bills Medicare for the additional test without the doctor’s knowledge. When the physician doesn’t have the option of ordering the standard panel without the extra test, the lab may be liable for claims submitted for the extra test.

Upcoding and Unbundling/Fragmentation

Billing Medicare and Medicaid for medical services is done using a complex system of numerical codes that designate various diagnoses and procedures. Reimbursements are based on those codes. The coded, computerized bills submitted by providers are processed by large insurance companies (known as “intermediaries” or “carriers”.) that contract with the Government to pay claims using Government funds. Because different codes or code combinations may produce dramatically different reimbursements from Government programs, there is a financial incentive to upcode or bill for a more serious (and more expensive) diagnosis or procedure.

Another common example of improper coding is called unbundling, also known as fragmentation. Medicare and Medicaid often have special reimbursement rates for a group of procedures commonly done together, such as typical blood test panels by clinical laboratories. Some health care providers seeking to increase profits will unbundle the tests and bill separately for each component of the group, which totals more than the special reimbursement rates.

Kickbacks

One of the most complicated and troubling aspects of the health care system involves hidden financial arrangements between various health care providers. There are a variety of improper arrangements where providers will provide some material benefit in return for other providers prescribing or using their products or services. In most instances, such arrangements are illegal. Doctors are supposed to decide on the most appropriate treatment for their patients without consideration of their own financial interests. Kickbacks often result in medically unnecessary treatment.

False Certifications and Information

Health care providers who submit Medicare and Medicaid claims containing false statements also may be liable under the False Claims Act. For example, in Florida five persons were involved in a scheme in which Medicare was fraudulently billed about $5.2 million for oxygen concentrators, nebulizers, medications and tests. Three men were ordered to pay $2.3 million in restitution, and were sentenced to 41, 46 and 51 months in jail, for paying physicians for prescriptions that they sold to two medical supply companies and a laboratory to use in billing Medicare. One of the company owners and one of the physicians who also had billed for house calls he did not make were convicted and given prison terms as well.

Lack of Medical Necessity

Some health care providers bill Medicare and Medicaid for services or procedures that are not medically necessary. They would be liable under the False Claims Act for those false billing practices. For example, a Florida chiropractor who owned several clinics required doctors whom he hired to order x-rays, diagnostic tests and other therapies regardless of the needs of the patients. He also billed for tests never given, such as pelvic x-rays, and submitted duplicate claims for the same services. He was sentenced to five years in prison and ordered to pay $1.6 million for defrauding Medicare, the Railroad Retirement Board and private insurers.

Fraudulent Cost Reports

Medicare reimburses health care institutions for certain costs in addition to paying for individual procedures and treatment. Virtually every hospital and many other providers submit cost reports to Medicare, which are used to calculate how much the Government will reimburse the provider for expenses related to patient care. This includes the costs of capital improvements like new medical equipment and bigger wards. Over the years, cost reports can represent billions of dollars in payments for some providers. Providers who knowingly inflate the costs they incurred, mischaracterize the nature of those costs or give the wrong percentage of their services dedicated to Medicare patients are liable under the False Claims Act.

Grant or Program Fraud

The federal and state Governments fund a variety of research and other specialized projects in the health care area. Typically, Government funds are targeted for a specific and narrow purpose, a specialized research project or medical care for a specific group. Sometimes the recipients of grant or program funds mischaracterize their qualifications, the basis of their research or the quality and extent of services they provide.

If you need help and want a free legal consultation, please contact a Medicare fraud lawyer at Hughes Ellzey, LLP by calling toll-free 888-350-3931, or send us your contact information using our Contact Form. An attorney will call you as soon as possible after receiving your contact information.