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Could You Spot Medicare Fraud If You Saw It?

According to the Centers for Medicare and Medicaid Services, as of February 2016, there were over 56,000,000 beneficiaries enrolled in the original Medicare and Medicare Advantage plans. Given the number of patients, just imagine how many Medicare claims are submitted every day. It’s no wonder the Medicare system is a target for fraud. With the volume of legitimate Medicare claims that are submitted, surely the government won’t notice a few thousand fraudulent ones thrown in to the mix, right? With help from whistleblowers, those fraudsters can be stopped and taxpayer dollars can be recovered. The False Claims Act permits whistleblowers to bring qui tam actions for fraud committed against the government. Qui tam whistleblowers may be entitled to a percentage of the government’s recovery.

If you are employed in the healthcare field – a doctor, dentist, nurse, therapist, medical biller, receptionist, aide, technician, patient advocate, etc. – would you know Medicare fraud if you saw it? Some Medicare fraud schemes are easy to spot– billing for patients that don’t exist using stolen Medicare numbers; billing Medicare for durable medical equipment that was never provided to the patient – others are not so obvious. Here are some other examples of Medicare fraud that aren’t always so easy to identify.

  • Billing separately for items that should be bundled and submitted under a single billing code;
  • Misrepresenting a diagnosis in order to have a test or service covered;
  • Continuing to bill for therapy or other services that are no longer medically necessary;
  • Ordering lab tests that are not medically necessary;
  • Failing to collect required co-payments or deductibles;
  • Completing Certificates of Medical Necessity without the patient first receiving an examination by a health care professional;
  • Offering incentives to Medicare beneficiaries, such as free groceries or transportation, to use a specific medical provider, pharmacy, or laboratory, etc.;
  • Billing group services as an individual service for each member of the group;
  • Billing for hospice services for individuals who have not received a terminal diagnosis;
  • Billing at doctor rates for services provided by a nurse;
  • Billing for brand name drugs when generic drugs were actually given; and,
  • Referring Medicare patients for certain “designated health services” to entities in which the doctor (or an immediate family member of the doctor) has a financial relationship.

If you have personal knowledge of Medicare fraud, you should act quickly to learn your rights from a knowledgeable qui tam whistleblower lawyer. Contact us at 877-915-4040 for a confidential and free evaluation of your case.

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