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Medicare and Medicaid Fraud

Medicare and Medicaid fraud are among the most common types of fraud on the government, costing billions of dollars each year. Since January 2009, the Justice Department has recovered more than $37 billion through False Claims Act cases, with more than $24 billion of that amount recovered in cases involving fraud against federal health care programs. In fact, fraud in the health care industry is such a problem that, when the Department of Health & Human Services released its budget for fiscal year 2015, it listed fraud prevention and the reduction of improper payments as “top priorities” for the current administration.

forms of medicare fraud

Medicare and Medicaid fraud can take a number of forms, including the following:

  • Upcoding. Upcoding is when a hospital or healthcare provider seeks payment from Medicare or Medicaid for higher and more expensive medical services than those that were actually performed. For instance, the government intervened in a lawsuit originally filed by Goldberg Kohn, Ltd. against IPC The Hospitalist Co. Inc. and its subsidiaries (IPC) – one of the largest providers of hospitalist services in the country – alleging that IPC engaged in a fraudulent upcoding scheme by encouraging its doctors to bill at the highest levels available, regardless of the level of service provided, and training physicians to use higher level codes and encouraging physicians with lower billing levels to “catch up” to their peers.

  • Overbilling. Similar to upcoding, overbilling for medication occurs when a doctor or health care provider charges Medicare or Medicaid inflated prices for medications or for medications that were not actually provided.

  • Kickbacks. Health care laws restrict the financial relationships that hospitals, physicians, and other health care providers can have with doctors who refer patients to them.  When a health care provider makes improper kickbacks or offers financial incentives for the referral of Medicare or Medicaid patients, the False Claims Act comes into play.

  • Unnecessary Medical Procedures. In some cases, a doctor will order unnecessary (and often expensive) medical procedures to be billed to Medicare or Medicaid in order to boost profits. According to some estimates, unnecessary surgeries might account for 10% to 20% of all operations in some specialties, including a wide range of cardiac procedures and many spinal surgeries.

The whistleblower attorneys at Goldberg Kohn are committed to protecting the rights of whistleblowers and fighting Medicare and Medicaid fraud and other types of healthcare fraud. If you suspect Medicare, Medicaid, or other health care fraud, or would like to discuss a possible False Claims Act case, contact us online to schedule a free, confidential appointment with one of our whistleblower attorneys.

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