Examples of Fraud for Healthcare Whistlelowers

What activities are considered healthcare fraud involving Medicare or insurance compensation.

Healthcare Employers and healthcare whistleblowers are always on the lookout for these types of activities involving Medicare or insurance compensation:

Paying for Patient Referrals:

Companies and individuals that pay others to refer over patients, such as (i) insurance brokers getting paid by healthcare providers, or (ii) a lab or diagnostics business paying a physician to send patients for testing, or (iii) certain physicians getting paid more by a hospital because they refer them patients, or (iv) a healthcare provider paying insurance personnel to pay for referrals. Healthcare employers and healthcare whistleblowers are on the lookout for payment for patient referrals when it comes to procedures paid for by Medicare or insurance providers.  

False Diagnosis of Medicare Advantage Patients:

Primary Care Physician (PCP) Practices or companies that encourage and promote claiming an exaggerated level of severity of a beneficiary's (or patient's) medical condition.  The higher the severity the higher the Medicare Advantage capitated rates from Medicare.  This occurs when the Medicare beneficiary enrolls in a Medicare Advantage health insurance plan sponsored by private insurance companies.  The PCP is then paid a capitated rate based on the forseen risk of the patient, not on the actual level of service provided.   The higher the perceived risk the higher the payment.  Hence certain PCPs push for exaggerated ratings, that would literally mean that the patient should be close to complete disability, or even death, yet the patient is in relatively good health and the PCP makes off with money.   

Denying Access to Medicare Advantage Patients:

Primary Care Physician (PCP) Practices or companies that encourage and promote claiming an exaggerated level of severity of a beneficiary's (or patient's) medical condition.  The higher the documented severity the higher the Medicare Advantage capitated rates from Medicare.  This occurs when the Medicare beneficiary enrolls in a Medicare Advantage health insurance plan sponsored by private insurance companies.  The less the patient uses medical services, the more money the PCP makes.  Hence the scheme involves the PCP denying the patient access to specialists services in order to keep the actual costs low.   The PCP is paid a capitated rate based on the foreseen risk of the patient, but the PCP denies access to the patient in order to keep the costs low and the profitability high.  

Billing under Medicare Advantage Capitated Contracts when Patient has not been seen:

Companies that intentionally enroll Medicare Advantage patients, and then fail to bring the patient into the office for initial medical assessment or failing to provide the patient access to medical care, and then billing for it.  Sometimes companies fall into billing for incarcerated patients, or patients that are out of the designated service area or even outside the country.  Not removing these patients from the billing system could lead to fraud upon the government.  Healthcare employers and healthcare whistleblowers are on the lookout for billing for patients that do not receive the appropriate services. 

Billing for services that are not medically necessary:

Medically unnecessary services and tests may include unnecessary inpatient admissions, advanced imaging, unnecessary tests or lab work, and other procedures. For example: the ordering of extra services that were never necessary and unrelated to the actual real reason why the patient came to see the physician. Healthcare employers and healthcare whistleblowers are on the lookout for unnecessary billing that increases in revenue dollars. 

Electronic Health Record (EHR) fraud:

Companies that gather and sell electronic health records systems and services may face liability for downstream improper storing and use of data.  It requires having downstream agreements, even with affiliated and subsidiary companies.  It also requires maintaining systems that meet government certification standards. In addition, providers and hospitals may face liability for fraudulently claiming EHR incentive payments, or for submitting fraudulent bills based on EHR systems designed to improperly increase reimbursements.  EHR marketing may also implicate unlawful kickbacks and other improper financial relationships. Healthcare employers and healthcare whistleblowers are on the lookout for electronic healthcare record fraud. 

Billing for unlicensed personnel:

This may include services provided by individuals who lack the skills or proper licenses, or services provided by trainees without the required supervision. For example: if a physician has a technician perform the services, and the business bills the insurance company as if the physician had performed the service. Healthcare employers and healthcare whistleblowers are on the lookout for services performed by unlicensed and unsupervised personnel that generate extra Medicare or insurance compensated revenue dollars. 

Physician's standing orders for unnecessary testing:

In one instance, a physician became the medical director of an addiction treatment facility and authorized "standing orders" for hundreds of millions of dollars worth of unnecessary tests; never to have actually read the test report. In return, the physician required the treatment facility to have their patients treated at his clinic.  Healthcare employers and healthcare whistleblowers should be on the lookout for physician's standing orders for testing every patient unnecessarily only to generate extra Medicare or insurance compensated revenue dollars. 

Billing for unauthorized locations:

This may include services performed at a facility that is inappropriate for that service, or a facility that is improperly staffed or equipped for the procedure. Or for example hospitals systems that bill for services at the higher hospital rates, even though the services were provided outside of the hospital. Healthcare employers and healthcare whistleblowers are on the lookout for unauthorized locations that are used to increase Medicare or insurance compensated revenue dollars.

Off-label marketing of prescription drugs:

“Off-label marketing” means that a drug is promoted for a use that was not approved by the FDA, such as marketing a drug designed for adults to be used by children. Another example is recommending a higher dosage than is approved. Healthcare employers and healthcare whistleblowers are on the lookout for drugs being marketed for off-label use to increase in revenue dollars for the drug companies. 

Discount or rebate and other pricing fraud:

Government healthcare programs pay for pharmaceuticals and devices at specified rates, often tied to specified cost metrics.  Misuse or manipulation of these programs can result in the submission of false claims. Healthcare employers and healthcare whistleblowers are on the lookout for improper discounts and rebates that increase revenue dollars for device manufacturers and pharmaceuticals from Medicare or insurance providers.

Clinical trials - FDA fraud :

The FDA relies on trial data to verify the safety and efficacy of drugs. If any party in the trial process misrepresents, omits, or falsifies the data, such FDA fraud can create far-reaching damage to future users of the drug. Healthcare employers and healthcare whistleblowers are on the lookout for falsification of trial data that increase revenue dollars for the provider. 

Compounding pharmacy fraud:

This fraud involves pharmacists mixing drugs or making large batches, rather than following strict procedures to meet the needs of individual patients. Healthcare employers and healthcare whistleblowers are on the lookout for unnecessary of compounding of pharmaceutical drugs that increase revenue dollars for the pharmacies. 

Healthcare Leases or Free Space to certain providers - Real Estate: 

Giving or receiving leased space from a hospital, clinic or lab, for free.  When the incentive for providing the free space is the amount of referrals the other business provides.  For example allowing an outside surgeon to setup an office inside a hospital for free or at a very highly discounted rate, when in reality it is being done because of the volume or value of referrals.   Similarly, a lab company that gives free space to a doctor because they expect referrals back from the doctor. Healthcare employers and healthcare whistleblowers are on the lookout for free benefits of space provided in exchange for referrals or Medicare or insurance compensated increase in revenue dollars. 

Hospital Satellite Facilities More than 250 Yards:

Billings done by a "hospital" are typically higher than billings rates of hospital satellite facilities, because it costs more to operate hospitals than other facilities.  If a building is more than 250 yards from the main hospital building it is considered a satellite facility.  Aggressive hospitals bill for satellite facilities that are near the main building but farther than 250 yards.  That is fraudulent billing causing insurance companies, Medicare and Medicaid to pay more than what should have been paid. Each geographically separate location that is more than 250 yards from any exterior wall of the hospital's main building need a separated license filing and a fee.   Healthcare employers and healthcare whistleblowers should be on the lookout for misclassification of buildings.   

Physician office conversions to Hospital Facilities:

Medical systems sometimes convert physician offices to hospital facilities.  When they do that they have to file certain paperwork and meet the requirements set forth by Medicare, Department of Health, and Agency for Health Care Administration, and obtain permits and licenses.  Some hospitals convert physician offices to hospital space only to bill at higher rates.  That is fraudulent billing causing insurance companies, Medicare and Medicaid to pay more than what should have been paid.   Healthcare employers and healthcare whistleblowers should be on the lookout for misclassification of building space.   

Remember you cannot win an Award unless you file a Lawsuit.

If you think you have a situation that you would like to discuss with an attorney in confidence, do not hesitate to contact me directly Ben A. S. Mirza, Cell/Text 954-445-5503 or email me at [email protected].  We are a team of lawyers ready and standing by to correct the wrong, and we will do our best to earn you an award.  We only make money if you get an award from the government. The right team of attorneys can make all the difference.  We stand by to earn your business.

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