Medical Fraud And The Whistleblower

10 Nov

Medical Fraud And The Whistleblower

What is a Medical fraud?

Medical fraud, also known as health care fraud, involves dishonest claim, waste and abuse of medical funds. These can involve patients, physicians, health care providers, pharmacists, beneficiaries and medical equipment companies.

What is Medicaid?

Medicaid is a state-administered healthcare program that offers health benefits to low-income individuals and families who do not have a medical insurance in place or have very limited medical insurance. These state-administered healthcare programs are the prime targets for medical frauds.

Who pays for the Medicaid claims?

The funds for the Medicaid claims come from the federal, state and country funds which is an accumulation of all the money paid by the taxpayers of the country. Medical frauds are considered white-collar crimes and there are various federal laws to convict individuals and companies involved in the fraud.

criminal-lawHowever, conviction alone is not enough to reduce these frauds. Civil suits can help recover the money lost and provide them to deserving patients. The state hence encourages people to report it when they suspect a medical fraud.

In addition to this, some states also have precautionary methods in place to detect frauds before they are paid to reduce the time and effort involved in chasing and recovery of fraudulent payments. These include data mining, risk analysis, pattern analysis to increase the number of frauds identified.

Why should you report Medical frauds?

When a medical fraud is committed it could involve patient abuse, especially of the elderly, where they might be denied a medical treatment, in addition to misappropriation of their rightful funds. On the other hand, patient abuse can also involve unnecessary procedures that could be harmful to the patient.

The funds are also made unavailable to other deserving patients. Hence, both the taxpayer as well as the rightful recipient of the medical aid is affected in the bargain.

 How to report a Medicaid fraud?

One of the ways to report a health care fraud is to contact the Office of Inspector General (OIG) either on their website or call the National Fraud Hotline. You will need to provide basic details as shown below.

  • Name of the client

  • Card number

  • Details of the doctor, hospital or the healthcare provider

  • Claim amount that is approved

  • Fraud acts applicable

As a Whistle blower, will you be protected?

Health care frauds are the most common form of False Claims Act violation. Private citizens can file lawsuits on those who commit fraud against the government. As a whistleblower you will become eligible for a whistleblower reward that could equal 15 – 30% of the amount recovered from a successful lawsuit.

State and Federal laws also offer protection to whistleblowers against any discrimination, suspension, harassment or other unpleasant treatment by their employer. They are also eligible for relief such as job reinstatement, double back pay, and court fee and attorney fees coverage. An experienced health care fraud lawyer can help you if you decide to file a lawsuit.

Who commits a medical fraud?

Both the patients and the people involved with health care can commit a medical fraud. In case of patients, it’s usually faking a medical condition or using another patient’s insurance information to gain health benefits.

Healthcare providers can commit medical fraud in many of the following ways

  • Double-billing – Billing more than once for the same services or supplies provided

  • Duplicate claims – Multiple claims for services provided

  • Mischarging – These include claims for procedures and services that are not delivered to the patient

  • Unbundling – Some procedures and tests are required to be bundled together as a package. These are deliberately charged as individual procedures to increase the billing amount.

  • Upcoding – This involves inclusion of unnecessary and expensive illnesses that are not found in the patient

  • Off-label marketing – Pharmaceutical companies encourage doctors to prescribe drugs that are not approved by the FDA (Food and Drug Administration)

  • Kickbacks for referrals – Payments are made to refer patients and products that are eligible for medical care

These types of medical frauds and the laws required to file a lawsuit can be a very tedious and confusing job for a whistleblower, not to forget that whistleblower lawsuits have shorter deadlines. A right health care fraud attorney becomes practically inevitable in these cases.