How to Report Medicare Fraud
Table of Contents
Medicare claims totaled about $740 billion in 2018. Meanwhile, the National Health Care Anti-Fraud Association estimates that $60 billion or more of that is lost to fraud each year. The federal government takes this fraud seriously; so seriously that it not only encourages Medicare beneficiaries to report suspected cases of fraud under the False Claims Act, but also offers whistleblowers a percentage of the funds recovered.
These facts represent precisely why you need to be able to recognize instances of Medicare fraud, why you need to understand how to report fraud, and why you must have an attorney experienced in reporting Medicare fraud to properly file a claim. An attorney from the team of the Bell P.C. Healthcare Fraud Group can accomplish all of these tasks.
Medicare fraud can take on many different forms. Anyone can commit it, and anyone can be a victim.
- Patients are particularly susceptible to becoming victims simply because of Medicare’s complexity. It’s difficult to track all of the billing codes from physician visits, diagnostic tests, hospital expenses, medical procedures, pharmacy purchases, home visits, and therapies. Patients may not even be aware of the charges being filed against them. Sometimes, however, you might notice that something just isn’t right. Most often your potential case of fraud isn’t the only one, and it might be time to blow the whistle and report it before someone else does.
- Doctors and other healthcare providers can also face fraudulent schemes. Professional networks can become referral pathways that place profit before the mission. A healthcare vendor’s business-as-usual practices may actually be unethical and illegal. Or, despite your best efforts, you may unknowingly have compromised yourself, your group, or your facility by violating a technicality in the laws. In those cases and numerous others, physicians and other medical professionals may find themselves acting in the role of whistleblower and in need of the protections that only legal representation can afford.
Individuals, physicians, healthcare professionals, institutions, companies, corporations, and even criminal organizations—anyone—can be guilty of violating key laws specifically designed to prevent fraudulent practices.
So, while anyone can be the victim of or even commit Medicare fraud, just about anyone can also do something about it by learning how to report fraud under the False Claims Act.
How Do I Report Medicare Fraud Under the False Claims Act?
The False Claims Act was originally created in 1863 to prevent wartime suppliers from defrauding the government. Today, the False Claims Act has become the primary way for whistleblowers to file the necessary qui tam claim against suspected Medicare fraud.
The term qui tam is key. It means that a private party—you, for example—can file a suit on the government’s behalf. You become what is termed the relator while the government becomes the plaintiff. In exchange, you can receive a percentage of any proceeds recovered from the defendant if the claim is successful. However, as the relator, you must follow specific steps in order for the government to recognize your claim. You must know not only how, but also where to report a medicare fraud.
- File. You must file the qui tam complaint with the court under seal. That means that the Clerk of the Court must keep all records regarding the case on a secret docket. A copy of the complaint in writing and a disclosure of all evidence and information pertinent to the complaint must then be served on the local U.S. Attorney where you filed the qui tam complaint and on the Attorney General of the United States.
- Wait. The qui tam complaint remains sealed for 60 days or more as the government investigates the claim.
- Decide. Once it finishes its initial investigation, the government can choose to dismiss, settle or pursue prosecution for the claim. Depending on what the government decides, you as the relator have options. Even if the government chooses not to intervene, you may still be able to pursue the claim.
- Collect. If your qui tam suit is successful, you may be able to collect anywhere from 15 to 30 percent of the amount recovered, as well as full reimbursement for any legal fees or other expenses you may have incurred.
Stakes can be high in these cases because the costs of healthcare are significant. In addition to fines for each false claim, defendants may face penalties that are triple the amount of damages that the Government sustained. Even with reduced damages available for self-reporters, the amount is at least double.
What Makes a Claim False Under the False Claims Act?
The False Claims Act broadly defines seven types of activities that it considers fraudulent:
- Knowingly presenting a false or fraudulent claim for payment or approval. This includes causing someone else to present a false claim.
- Knowingly making, using, or causing someone else to make or use a false record for a fraudulent claim.
- Knowingly delivering less money or property to the government than was entrusted to you.
- Intending to defraud the government by making or delivering a receipt for property intended for the government without ensuring that the information on the receipt is true.
- Knowingly buying government property from a government employee not authorized to sell or pledge that property.
- Knowingly using, making, or causing someone else to use or make a false record or statement concerning money or property owed to the government. This includes knowingly concealing or decreasing the amount of money or property due the government.
- Conspiring to commit any of the other six listed crimes.
What Everyday Medicare Fraud Looks Like
In short, the False Claims Act prohibits providers from submitting false claims like billing for services, procedures, or materials that they did not actually deliver, perform, or use. Examples of what that may look like may be startlingly familiar:
- A specialist might submit billing for more residents of an assisted living center than they actually treated.
- Providers might submit billing for the full number of covered consultations but actually schedule only a fraction of them to treat the patient.
- Providers might submit charges for a covered entitlement even though they performed a noncovered service. They might substitute pricier codes in place of the appropriate but far less lucrative ones. They might even unbundle codes to bill each step of a procedure as a standalone procedure.
- A supplier might bill for higher grades of equipment or greater quantities of materials than they actually delivered.
- Providers might alter diagnoses or records to be able to order unneeded tests or other medical procedures or treatments.
All of these scenarios should prompt one question: How do I report a Medicare fraud? That’s why Bell P.C. and the Healthcare Fraud Group are here. We want you to be able to recognize and know how and where to report fraud.
The Full Extent of Reporting Medicare Fraud
What’s important to realize is that anyone can attempt to commit Medicare fraud—regardless of whether they have any real or professional association with the healthcare community. Individuals, physicians, healthcare professionals, institutions, vendors, companies and corporations, and even criminal organizations can be guilty of violating the False Claims Act, as well as several other key federal laws that address specific fraudulent healthcare practices that involve false claims.
- Anti-Kickback Statute—The AKS bars any kind of reward, also known as a kickback, for referrals for any services or goods reimbursable through federal healthcare programs. Kickbacks cannot be offered or received, and although they often take the form of incentives or rewards other than cash, they’re still illegal.
- Physician Self-Referral Law—Also known as the Stark Law, the Physician Self-Referral Law prevents physicians from referring Medicare patients to facilities or other services that the doctor or the doctor’s immediate family has a financial relationship with.
- Federal Health Care Fraud Statute—The FHCFS prohibits schemes and what are often scams fraudulently offering to deliver or pay for healthcare benefits, equipment, home care items, or services through Medicare.
- Exclusion Statute—The Exclusion Statute bars providers that have been convicted of certain serious healthcare-related crimes from participating in any federal healthcare programs.
Qui tam claims under the False Claims Act are effective tools for fighting and reporting Medicare fraud. They benefit the government and the general public, but they rely on whistleblowers who understand that they must enlist the help of an attorney to properly file them.
In fiscal year 2018, the Department of Justice recovered $2.8 billion under the False Claims Act, and $2.5 billion of that was related to healthcare. In that same year, 645 new qui tam claims were filed $2.1 billion were recovered through qui tam claims.
By the Justice Department’s own admission, “the False Claims Act has a very detailed process for the filing and pursuit of these claims,” and the first requirement is that “the qui tam relator must be represented by an attorney.” The reason for this requirement is that as a relator, you are acting on the government’s behalf. Since the government must use attorneys to negotiate or prosecute cases, you must also use an attorney.
- The government benefits because an attorney experienced in prosecuting cases under the False Claims Act provides a degree of legal vetting that the complaint is authentic, fact-based, and worth consideration.
- You benefit because that same experienced attorney understands the complexity of the specific steps you must take to file your complaint properly and remain the relator in the case. Missed deadlines, incomplete or ineptly presented complaints, and incorrect filings are just a few of the problems that can jeopardize a claim. The government can request multiple six-month extensions to investigate your complaint as it determines whether it will take one of the following courses of action:
- Intervene. The government can choose to prosecute one, several, or all counts in your complaint. If it intervenes, your award will be 15 to 25 percent of the proceeds recovered.
- Decline to intervene. The government leaves prosecution to you, the relator, and your attorney to pursue. If you are successful, your award will be 25 to 30 percent of the proceeds recovered.
- Move to dismiss the complaint. Your complaint may duplicate another (an earlier one for example).
- Settle. The government may agree to settle the claim.
In each of these scenarios, your attorney’s experience and expertise directly affect how your claim is viewed within the justice system and the impact that it can have.
At Bell P.C., we’ve built a team of respected, knowledgeable lawyers and legal professionals that specialize in resolving the high-stakes legal conflicts inherent to the federal healthcare system. Together, we represent more than a century’s worth of experience in handling high-risk, high-visibility cases with the potential for significant terms of imprisonment, heavy fines, and irreparable damage to reputations with discretion and sensitivity.
Our collaborative nationwide network benefits from the expertise of former federal defense attorneys and prosecutors who understand the complexities of federal laws, investigations, and trials and appeals. Our track record within the healthcare system speaks for itself. We’ve gained clients multi-million-dollar settlements in confidential disputes and successfully served as lead counsel in qui tam lawsuits. We’ve won cases for medical centers, pharmaceutical companies, and private clients, and we know exactly how and where to report a Medicare fraud.
We’ve even taken on the big banks. We achieved the ninth-largest verdict in U.S. history by winning a $6 billion decision against JPMorgan Chase for malice, fraud, breach of fiduciary duty, conversion, and gross negligence.
Nevertheless, federal healthcare fraud remains our focus as we offer our clients dedicated assistance with cases and investigations under the jurisdiction of the Department of Justice, the Drug Enforcement Administration, the Centers for Medicare & Medicaid Services, the Department of Health and Human Services, the Office of the Inspector General, the Federal Bureau of Investigation, and the Internal Revenue Service.
If you suspect Medicare fraud or if your health care business, practice, or organization is under investigation for Medicare fraud, you need the skilled attorneys at the Healthcare Fraud Group. Call us at 888-402-4054, or visit us online to schedule a confidential consultation. Anyone can commit Medicare fraud, and anyone can report a Medicare fraud, but only a good lawyer with a solid team can achieve the resolution you deserve.
https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/Downloads/TR2019.pdf page 10
CMS Report from February 2019—very thorough
False Claims Act—3730 explains terms
FCA US Code 31, Sections 3729-3733 https://uscode.house.gov/view.xhtml?path=/prelim@title31/subtitle3/chapter37/subchapter3&edition=prelim
AKS US Code 42, Section 1320a-7b(b)
Stark Law US Code 42, Section 1395nn
CHCFS US Code 18, Section 1347
Exclusion Statute US Code 42, Section 1320a-7
Qui tam statistics https://www.justice.gov/opa/pr/justice-department-recovers-over-28-billion-false-claims-act-cases-fiscal-year-2018