Medicaid and Medicare are two governmental insurance programs that provide medical and health-related services to specific groups of people in the United States. Although the two programs are very different, they are both managed by the Centers for Medicare and Medicaid Services, a division of the U.S. Department of Health and Human Services. Medicare, the federal health insurance program for over 50 million elderly and disabled Americans, helps to pay for hospital and physician visits, prescription drugs, and other acute and post-acute services. Medicaid provides health coverage to more than 50 million children, families, pregnant women, the elderly, and people with disabilities. Both Medicare and Medicaid are amendments to the Social Security Act signed into being under President Lyndon B. Johnson on July 30, 1965.
Examples of Medicare and Medicaid Fraud
Medicaid and Medicare fraud can be committed by many different types of individuals and organizations within the system. Some of the areas and individuals who can be responsible for commiting fraud include, but are not limited to, doctors, nurses, hospitals, durable goods providers, pharmacies, laboratories, medical service companies, home health care agencies, nursing homes, and medical sales representatives. If a provider receives reimbursement for its services from Medicare and Medicaid based upon a false premise, the reporting individual has a right to participate in the money returned to the federal government in accordance with the False Claims Act. Medicare fraud may take many different forms. It commonly occurs on the medical side, where doctors falsify their records to increase their Medicare or Medicaid earnings or benefits.
- Billing-related fraud, including:
- Services never delivered are the submission of a claim for services that were never provided to the patient, but submitted as completed for the higher reimbursement for the benefit of the medical facility or professional. These include, but are not limited to, tests, diagonosis, health care services, treatments, prescriptions, medical device delivery or other services.
- Doctors or hospitals over-inflating the number of patients served or providing Medicare patients with unnecessary medical treatments to maximize their reimbursement.
- Medical suppliers charging Medicare for equipment or services they never fulfilled.
- Medical transportation providers claiming longer than actual mileage for Medicare paid trips.
- Medical providers including personal expenses when billing for professional services.
- Lack of necessity, is where a healthcare professional knowingly misleads on claims by requesting services, devices and procedures for a patient that the individual does not need, enabling a higher billable amount to the professional or healthcare facility from Medicare or Medicaid.
- Unbundling, which is the concept where a healthcare professional bills separately for services and procedures which typically are "bundled" together to make them more expensive, resulting in a larger reimbursement amount from the Medicare or Medicaid facilities for the hospital or organization.
- Medical school passing services performed by a resident as if they were performed by a physician.
- Upcoding, which refers to when a health care professional submits a bill but knowingly mislabels the standardized billing code in order to receive a higher payment or reimburseable amount.
- False Certification is when a health care professional or facility knowingly misleads patients or service providers regarding their qualifications when they are out of compliance with a requiremnt, or allowing someone with a lower certification to fill in for a role or service for which they are not qualified to administer.
- Research grant fraud typically entails some combination of providing false information on a government grant application, overbilling costs and other expenses covered by a grant, falsifying research data and results, inappropriate utilization of grant funds and undisclosed conflicts of interest for the principal investigators;
- Improper financial interest can exist, whereby a physician or other health care provider has a direct or indirect financial interest in services provided to their patients, including a prohibition on investment interests and compensation arrangements with entities that perform services to which they refer patients or from which they order goods and services paid for by Medicare or Medicaid;
- "Kickbacks" or paid referrals by physicians or pharmaceutical representatives payable by Medicaid or Medicare, including but not limited to referral fees, bonuses, extravagant vacations, equity ownership, finder’s fees, research grants, speaker's fees, travel expenses, professional sporting event tickets, discounted leases or equipment rental, family assistance, or forms of entertainment. These are also referred to as "inducements" may cloud the judgement a doctor or nurse may exercise when prescribing a prescription, procedure or service, and are illegal in all forms. Further, the patient's well being may take back-seat to the doctor's financial or personal gain.
- Off-Label Use typically entails a medical professional prescribing or a drug company advertising a drug for a use for which it is not yet approved of by the FDA. Often times un-approved analysis are drafted and shared to falsely validate unproven benefits of specific drugs. All drugs are prohibited from being sold for anything beyond its approved, intended use, as per the written label.
- If upon use doctors or pharmaceutical companies recognize added benefits of the drug, the company is required by law to submit a "New Drug Application" with the FDA before it can be marketed or prescribed. Though an added cost of time and money to doctors and pharmaceutical companies, until the drug is approved, off-label marketing is illegal. Pro Publica has reported that almost $7 billion have been paid by pharma companies in settlements for off-label marketing over the last three years alone. An article below expands on this point.
Be Rewarded for Stopping Medicare & Medicaid Fraud
Stopping fraud and abuse in the American healthcare systems is everyone's responsiblity. Every dollar you save the government allows it to be applied appropriately to help our neighbors and to protect our world for future generations, improving the quality of life across our country for everyone. If you have knowledge of deception by a doctor, a hospital, a patient, a health insurance specialist, a medical technologist, a nurse consultant, a pharma sales rep or a healtcare adminstrator - perhaps even you yourself have been pressured into advocating off-label uses for FDA approved medicines, pushing for illegal alien patients over American citizens to receive higher Medicare reimbursements for certain treatments, or requesting for Medicaid reimbursements for services never provided - then your desire to do the right thing and fix these crimes can be rewarded.
Speak to someone with OffRecord to assess the merits of your claim and see if they are the right partner to help protect our healthcare system and make our nation healthier for everyone. Most importantly, see if we can be the right partner to help protect your identity and career while changing behaviors that hurt our country, so individuals who resist these social pressures can be rewarded. For every dollar you save the government, the False Claims Act requires that the judge award 15% to 30% of that savings in a reward. In some cases there are maximum time frames for which a crime can be reported; therefore, it is important for you to take action sooner rather than later.
