Healthcare employees, such as medical directors, physicians, pharmacists, and medical coding and billing professionals, may witness questionable practices at work like unusual billing patterns or pressure on providers to perform unnecessary procedures. If you suspect a hospital of fraud, the whistleblower attorneys at Goldberg Kohn can help you evaluate your claims.
What Is Hospital Fraud?
Goldberg Kohn specializes in hospital fraud cases in which hospitals intentionally deceive government programs like Medicare, Medicaid, or TRICARE. Honest mistakes do not constitute fraud. Instead, hospital fraud entails knowing and systematic schemes.
Common Hospital Fraud Scheme Examples
Fraud can take many forms. Some common schemes include:
- Upcoding: Billing for more expensive or complex medical services, procedures, or diagnoses than what was actually provided. Providers use inflated billing codes to receive higher reimbursement from insurers, rather than accurately reflecting the care delivered.
- Unbundling: Illegally billing separately for individual components of a medical service that should be grouped and billed under a single, comprehensive code. This practice artificially inflates the total charges to gain higher reimbursement than allowed for bundled procedures.
- Billing for services not rendered: Submitting claims for medical services, tests, procedures, or items that were never actually provided to the patient. Examples include charging for appointments that didn't occur or equipment that was never delivered.
- Medically unnecessary services: Billing for healthcare services, supplies, or equipment that are not medically necessary for a patient's diagnosis or treatment. This fraud often involves performing unneeded procedures or admitting patients unnecessarily to generate revenue.
- Illegal kickbacks: Offering or accepting remuneration to induce patient referrals for services covered by federal healthcare programs. These kickbacks corrupt medical decision making and violate the Anti-Kickback Statute.
- Self-referrals: Physicians referring patients from entities with which the physician or one of their immediate family members has a financial relationship. If the services covered by the referral are payable by Medicare or Medicaid, the referral may violate the Stark Law.
- Duplicate billing: Submitting multiple claims for the same medical service or procedure for the same patient on the same date. This action results in receiving payments more than once for a single instance of care.
The Whistleblower’s Role in Fighting Hospital Fraud
Whistleblowers are essential in combating hospital billing fraud. The False Claims Act (FCA) allows individuals with evidence of fraud against the government to file a lawsuit on the government's behalf. With the help of whistleblowers, the government has recovered billions of dollars lost to government fraud. Since 1986, relators suing under the FCA have exposed almost 17,000 fraudulent schemes and helped the government recover over $55 billion in settlements and judgments.
The FCA provides robust legal protections against whistleblower retaliation (such as firing or demotion). If the government recovers from the whistleblower’s action, the whistleblower is entitled to a percentage of the funds recovered.
Frequently Asked Questions
How does hospital fraud affect patients?
Hospital fraud can lead to higher healthcare costs, unnecessary medical procedures, and compromised patient care.
How does hospital fraud affect taxpayers?
Hospital fraud drains government healthcare programs like Medicare and Medicaid, costing taxpayers billions of dollars each year.
What laws are used to combat hospital fraud?
The FCA, the Anti-Kickback Statute, and the Stark Law are the primary laws whistleblowers can use to combat hospital fraud on government healthcare programs. The FCA empowers whistleblowers to file lawsuits on behalf of the government.
Who can be a whistleblower in a hospital fraud case?
Anyone with insider knowledge of hospital fraud can be a whistleblower, including employees and former employees.
What protections are available to hospital fraud whistleblowers?
In FCA cases, most relators ultimately cannot remain anonymous. However, the FCA includes provisions designed to protect whistleblowers — for example, FCA cases are initially filed under seal. This means that when a case is first filed, the relator’s identity is not disclosed.
Additionally, the FCA prohibits employers from retaliating against whistleblowers, and it allows whistleblowers to seek relief should they face discharge, demotion, suspension, threats, harassment, or other forms of discrimination.
What kind of information is helpful in a hospital fraud case?
Helpful information includes billing records, patient files, internal communications, contracts, and any other documents that demonstrate fraudulent activity.
How do I report hospital fraud?
Goldberg Kohn can help you file a qui tam lawsuit under the Federal FCA and/or state False Claims Acts.
What happens after I file an FCA case reporting hospital fraud?
The government will investigate the allegations while the case is under seal. The investigation may include an interview with the whistleblower. Once the government concludes its investigation, it will either decide to take on the case, allow the whistleblower to pursue the case independently, or dismiss the case. If the government takes on the case or allows the whistleblower to pursue the case, the whistleblower is entitled to a percentage of any recovered funds.
What is NOT hospital fraud?
A simple disagreement on the best course of treatment between a doctor and a patient, or an isolated billing error is not hospital fraud. Honest mistakes in medical judgment, without intent to deceive or defraud, are also typically not considered fraud. To be successful, fraud cases must be based on a systematic scheme.
Contact Goldberg Kohn to Discuss Your Situation
You can call us at 312-284-3258 or contact us online. We are always willing to provide you with a free, confidential consultation to discuss a potential case.