Health care fraud

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Health care fraud includes health insurance fraud, drug fraud, and medical fraud.

Health insurance fraud occurs when a company or an individual defrauds an insurer or government health care program, such as Medicare (United States) or equivalent State programs. The manner in which this is done varies, and persons engaging in fraud are always seeking new ways to circumvent the law. Damages from fraud can be recovered by use of the False Claims Act, most commonly under the qui tam provisions which rewards an individual for being a "whistleblower", or relator (law).[1]

Recent News and Statistics[edit]

The FBI estimates that Health Care Fraud costs American tax payers $80 billion a year.[2] Of this amount $2.5 billion was recovered through False Claims Act cases in FY 2010. Most of these cases were filed under qui tam provisions.

Over the course of FY 2010, whistleblowers were paid a total of $307,620,401.00 for their part in bringing the cases forward.[3]

Types of Fraud[edit]

There are several different schemes[4] used to defraud the Health care system.

  • Billing for services not rendered
  • Upcoding of services
  • Upcoding of items
  • Duplicate claims
  • Unbundling
  • Excessive services
  • Unnecessary services
  • Kickbacks

Billing for services not rendered[edit]

Often done as a way of billing Medicare for things that never happened. This can involve forging the signature of those enrolled in Medicare, and the use of bribes or "kickbacks" to corrupt medical professionals.[4]

Upcoding of services[edit]

Billing Medicare programs for services that are more costly than the actual procedure that was done.[4]

Upcoding of Items[edit]

Similar to upcoding of services, but involving the use of medical equipment. An example is billing Medicare for a power-assisted wheelchair while only giving the patient a manual wheelchair.[4]

Duplicate Claims[edit]

In this case a provider does not submit exactly the same bill, but changes some small portion like the date in order to charge Medicare twice for the same service rendered. Rather than a single claim being filed twice, the same service is billed two times in an attempt to be paid twice.[4]

Unbundling[edit]

Bills for a particular service are submitted in piecemeal, that appear to be staggered out over time. These services would normally cost less when bundled together, but by manipulating the claim, a higher charge is billed to Medicare resulting in a higher pay out to the party committing the fraud.[4]

Excessive Services[edit]

Occurs when Medicare is billed for something greater than what the level of actual care requires. This can include medical related equipment as well as services.[4]

Unnecessary Services[edit]

Unlike excessive services, this fraudulent scheme occurs when claims are filed for care that in no way applies to the condition of a patient, such as an echo cardiogram billed for a patient with a sprained ankle.[4]

Kickbacks[edit]

Kickbacks are rewards such as cash, jewelry, free vacations, corporate sponsored retreats, or other lavish gifts used to entice medical professionals into using specific medical services. This could be a small cash kickback for the use of an MRI when not required, or a lavish doctor/patient retreat that is funded by a pharmaceutical company to entice the prescription and use of a particular drug.[4]

People engaging in this type of fraud are also subject to the federal Anti-Kickback statute.

Examples of Fraud Cases[edit]

In the case United States ex rel. Donigian v. St. Jude Medical, Inc., No. 06-CA-11166-DPW (D. Mass.) St. Jude Medical, Inc. agreed to pay $16 million to quiet allegations of paying kickbacks to physicians. The whistleblower was able to provide detailed insider information as to the nature of the kickbacks, which ranged from entertainment to sporting event tickets and other gifts. The relator in this case was awarded $2.64 million.[citation needed]

The case United States et al., ex rel. Jim Conrad and Constance Conrad v. Forest Pharmaceuticals, Inc, et al., No. 02-cv-11738-NG (D. Mass.) involved a drug manufacturer selling a drug, Levothroid, that had never been approved by the FDA. These allegations settled for $42.5 million due to multiple whistleblowers stepping forward to provide detailed information on the alleged fraud. The collective reward to the relators in this case was over $14.6 million.[citation needed][5]

Reporting Fraud[edit]

There are many ways to report cases of fraud. If a patient or health care provider believes they have witnessed Health Care Fraud, they are encouraged to contact the FBI via either their local office, telephone, or the online tips form.

If, however, they want to ensure the government actively investigates the alleged fraud, they are encouraged to contact legal counsel from an experienced firm that specializes in qui tam litigation under the False Claims Act. A good legal team can advise potential whistleblowers of their rights, protections, and what evidence is necessary to solidify a case against the group leading the fraud.

See also[edit]

References[edit]

External Links and Resources[edit]

  1. Masterminds Behind Pharmaceutical Fraud Deserve Prison Time
  2. The Future of the False Claims Act
  3. CGMP Violations may be the Basis for Qui Tam
  4. Blowing the Whistle on Health Care Fraud
  5. Health Care Fraud Prevention(Page no longer available for view)
  6. FBI Tips Online