The numerous ways healthcare fraud can occur and the lack of a workforce to investigate claims make it difficult to stop. It’s a lucrative business, and several fraudsters who have been exposed say it’s easy to get away with – until it isn’t.

Lawsuits involving Medicare fraud are making headlines regularly. Investigators frequently expose and charge people with healthcare fraud, yet billions are still lost each year. Some fraud operations go on for decades before being shut down. 

Some criminals have been caught and jailed; others have reached settlements to pay back what they stole. Recently, a $900 million settlement was reached with Biogen, a pharmaceutical company that paid kickbacks to doctors who prescribed their medications. This case highlighted how profitable false claims against federal programs can be and how important whistleblowers are in stopping illegal activities.

For every successful Medicare fraud lawsuit, dozens more schemes are on the horizon. And unfortunately, those who need medical services and support are the ones who suffer the most.

The sheer size of the U.S. population and the many ways Medicare and Medicaid can be defrauded has created a multi-billion-dollar fraud industry.

Patient medical information is being stolen and sold. In some cases, physicians receive kickbacks for directly scamming healthcare programs; they misrepresent and outright falsify patient diagnoses to increase reimbursement amounts from Medicare and Medicaid. Healthcare workers are suffering as well; their professional information is often sold so that criminals can file claims and keep the payments for themselves.

Another popular way that Medicare fraud occurs is through fake companies. Criminals purchase or lease business space to make the company look legitimate when their stores and offices are mostly or completely empty. Many of them open, defraud the system, close, and then cross state lines to do it all over again.

Phone scams have also become rampant in recent years. Scammers act as representatives of Medicare and ask the person, who is usually elderly and vulnerable, for their social security number. The gathered information is then sold to other criminals to complete the fraud.

Hacking is another way beneficiary numbers and health worker information are stolen and used in schemes. Because the fraudsters have legitimate information to submit in their false claims, it’s especially difficult to catch. 

healthcare worker at desk with a computer doing Medical Coding And Billing Spreadsheets

Types of Healthcare Fraud

Common types of healthcare fraud that generate massive amounts of annual losses include:

  • False billing for services, treatments, and medical supplies or devices
  • Charging for more expensive services than what was delivered (upcoding)
  • Double billing
  • Claims made under stolen Medicare numbers
  • Drug plans sold by companies that aren’t approved by Medicare
  • Separating a service or procedure into several individual claims when one code could be used, all so they can bill a higher amount (unbundling)
  • Providing medically unnecessary services or treatments
  • Falsifying diagnoses to make unnecessary claims
  • Filing a claim for an ineligible patient

There are many ways to commit healthcare fraud, and the possibility of millions in profits is enticing. And individuals or businesses are not the only ones defrauding Medicare; there are entire networks with dozens of people working together to commit these crimes. Holding those who steal from the healthcare system responsible is crucial, but doing so is fraught with serious challenges.

Healthcare fraud convictions involve financial penalties and/or prison time. Base crimes can mean up to 10 years in prison, whereas anything causing injury can be up to 20 years. Fraud criminals could face life in prison if a death occurs because of their actions.

How Whistleblower Lawsuits Can Help Stop Healthcare Fraud

When hospitals commit Medicare/Medicaid fraud, their crimes can have far-reaching consequences for innocent patients who need medical care and taxpayers who must compensate for the financial losses. Often, this is done by decreasing government health insurance benefits or raising private insurance rates.

Without whistleblowers, billions of dollars in abused funds would never be recovered. Those who choose to blow the whistle on wrongdoing are risking their jobs and reputations to help victims of fraud. Fortunately, there are laws that protect whistleblowers from employer retaliation. In some cases, whistleblowers receive sizable compensation as a reward for their efforts.  

Successful whistleblower lawsuits demonstrate to would-be fraudsters that they are vulnerable to prosecution and often discourage them from trying. Every winning case is a step forward in the fight against healthcare fraud. 

The Medicare fraud attorneys at Herman Herman Katz fight for the rights and protections of brave whistleblowers. We will be with you every step of the way, ensuring your employer cannot retaliate against you and that you get the highest amount possible if you are entitled to a financial award. Medicare fraud whistleblowers are heroes who deserve to be treated as such.

If you have suspicions or proof of Medicare or other healthcare fraud at your hospital or medical center, please contact us online or call 1-844-943-7626 for a free and confidential case review.

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