Millions of dollars are billed to government healthcare programs and private insurance companies every day in the United States. Healthcare programs like Medicare and Medicaid provide sick and injured Americans with vital coverage for a wide range of medical care and life-saving treatments.
While these programs ensure those enrolled are supported when they have certain medical needs, it’s estimated that Medicare suffers at least $60 billion in losses due to healthcare fraud each year. It’s easily the costliest form of fraud in the U.S., and only a small portion of losses are ever recovered. But a lot of what is recovered comes from the help of whistleblower lawsuits.
A combination of factors contributes to how hospitals commit Medicare fraud. These include the sheer number of daily claims sent to government programs, use of electronic records and billing systems, lack of oversight and audits, size of hospital networks, and lack of control over fee codes.
Healthcare fraud at hospitals hurts the very people these programs exist to help; taxpayers help fund Medicare and Medicaid. It even raises insurance premiums among private insurers and limits the level of coverage the government can provide through Medicare.
But the patients that hospitals use to defraud healthcare programs can also suffer tremendously. They undergo unnecessary tests and procedures, are charged for services and treatments they never received, and their medical records are compromised.
Ultimately, Medicare fraud amounts to extensive financial and personal losses each year, and countless innocent victims and organizations end up paying the price.
How a Whistleblower Attorney Can Help
Holding hospitals accountable for defrauding a healthcare system designed to help Americans is crucial. When hospitals commit healthcare fraud, there’s a ripple effect of negative consequences. It affects the people who need medical care, costs taxpayers more money, decreases the amount of coverage provided through government health programs, and raises health insurance premiums.
Greedy hospitals and networks of health facilities focused on profit over patient care exploit the system. Their actions call into question the type of care provided to patients when money is at the forefront of how they’re treated. After all, hospitals have made billions more than they’re entitled to from publicly funded programs.
Due to how these crimes are committed, Medicare fraud lawsuits rely heavily on whistleblowers to expose hospitals and staff that make false claims. Collecting evidence needed to prove fraudulent activities is challenging without the help of the individuals who discover immoral and unethical practices in their workplace – and want to do something about it.
Given the complexity of whistleblower lawsuits involving healthcare fraud, hiring a law firm that handles False Claims Act cases is crucial. The highly experienced Medicare fraud attorneys at Herman, Herman & Katz have helped fight for the rights of whistleblowers and provided legal guidance throughout all stages of these lawsuits. If in compliance with applicable laws, whistleblowers may be financially rewarded for helping to prove healthcare fraud, and our team of competent attorneys has protected the rights of these brave individuals.
If you suspect or know firsthand that the hospital you work for is defrauding Medicare or another government program, contact us online or at 1-844-943-7626 for a free and confidential consultation.
About Healthcare Fraud at Hospitals
When a hospital intentionally steals or misuses taxpayer money from Medicare or Medicaid, it’s considered fraud. Far too many hospitals improperly bill healthcare programs, leading to reimbursement for more than they’re owed.
In most Medicare fraud cases involving hospitals, an employee – whistleblower – comes forward with allegations of wrongdoing. They could be doctors, nurses, administrative staff, or other employees. With the help of hospital fraud whistleblowers, evidence of illegal activities is gathered. Employees have access to proof of wrongdoing, like fraudulent records and cost sheets, that the government couldn’t easily collect or access without someone inside the organization.
Lawsuits involving Medicaid or Medicare fraud fall under the False Claims Act, which prohibits the filing of false claims made to federal programs. Thanks to the Act, hospitals that submit illegal claims to government healthcare programs can be held accountable for doing so.
“Qui tam” is a provision of the False Claim Act that essentially allows the whistleblower to sue on behalf of the government, and they help collect what’s needed for prosecution. Due to their role, qui tam gives whistleblowers incentive to come forward by awarding them a percentage of the funds recovered by the government.
Historically, many whistleblowers have received millions of dollars because Medicare fraud lawsuits usually lead to the recovery of hundreds of millions of dollars, if not more, before the guilty party is caught. And while many hospital workers who discover fraud taking place are worried about retaliation from their employers, their jobs are protected under specific whistleblower laws. This is important because once the whistleblower lawsuit is filed, the hospital could try to take it out on who exposed the illegal activities.
Types of Medicare Fraud at Hospitals
Unfortunately, hospitals across the U.S. have been fraudulently using healthcare programs like Medicare and Medicaid for decades, and they’ve done so in several ways. In fact, many hospitals use a combination of practices to defraud the system, resulting in millions, sometimes billions, of dollars in reimbursements they never should have received.
From submitting false cost reports and expensing care that wasn’t provided to admitting patients when it isn’t necessary and falsifying diagnoses, hospital Medicare fraud is not a victimless crime. With so many ways to defraud government healthcare programs, whistleblower lawsuits are integral in providing the evidence that proves crimes committed in the hospital setting.
1. Billing for Care Not Received
In many healthcare fraud cases, services, treatments, and tests that weren’t provided or performed are billed to Medicare. Hospitals are then reimbursed for something the patient didn’t receive. This may also occur when part of a patient’s hospital visit doesn’t have a billable fee, yet they submit a code with a cost under government healthcare programs.
Patient care at hospitals has codes for billing Medicare and Medicaid. Sometimes hospitals overcharge these programs by submitting codes for medical care that’s more expensive than what was provided. This type of fraud is called upcoding.
3. Falsifying Diagnoses
A false diagnosis is one of the worst ways patients are exploited in order for hospitals to line their pockets. Patients are put through invasive and traumatic tests and procedures that aren’t necessary, all due to profit-driven facilities. Doctors may enter a false diagnosis in charts to submit claims for more types of care and treatment, leading to greater compensation for the hospital and, sometimes, individual doctors.
Many medical procedures require several steps, and healthcare programs have codes covering the entire process. When a single code exists for the care received, but the provider breaks it down into multiple medical codes, the bill to Medicare and Medicaid is higher. It’s referred to as unbundling and is yet another way hospitals commit fraud.
5. Duplicate Billing
Duplicate billing is a form of healthcare fraud at hospitals that involves submitting claims to both Medicare and the private insurance companies of patients. The hospital ends up being reimbursed twice.
6. False Cost Reports
In addition to providing coverage for tests, procedures, and treatments, Medicare also reimburses hospitals for expenses they incur to provide care, such as new medical equipment. Fees for these expenses are detailed in cost reports that hospitals submit to healthcare programs. Far too often, cost reports are inflated so that the hospital receives more money than they’re legally entitled to.
7. Unnecessary Inpatient Admissions
When a patient is admitted to the hospital, it costs more. Hospitals commit healthcare fraud by admitting people when it’s unnecessary, all so they can charge more. Inpatient admissions when there’s no true medical need are fraudulent.
Herman, Herman & Katz can help file a whistleblower claim and ensure that you are protected to the full extent under the law. To learn more about medicare fraud whistleblower lawsuits, contact us online or call 1-844-943-7626 for a free, confidential case evaluation.