It’s estimated that in the United States, more than $100 billion is spent fraudulently on healthcare every year. Most commonly, healthcare fraud involves a government program meant to supplement or provide healthcare for a person. This crime is considered especially serious because it deprives people who actually need the medical services of medical care. The most common fraud claims go through these programs:
- Medicare, a federal program for healthcare that provides healthcare services and insurance for individuals over the age of 64. Medicare also provides these services for people with certain disabilities or developmental conditions.
- Medicaid, a joint federal and state healthcare program that provides healthcare services to low-income people and insurance based on need. medicaid also covers disabled people, blind people, and elderly people.
- Tricare, a military healthcare program that the United States Department of Defense operates. Tricare was previously known as “CHAMPUS.” It provides healthcare services and benefits to military service members, veterans, and their families.
If an individual successfully places a fraudulent healthcare claim, they can garner a number of rewards.
The most common type of healthcare fraud scheme involves medical billing. Billing fraud occurs when a healthcare provider or individual manipulates or alters a set of billing codes that are required by Medicaid and Medicare. There are a number of different ways that billing fraud might occur, but most often they’ll take the following forms:
- Double billing, which is the repeated billing of the same good or service
- Mischarging, which regards bills for unnecessary medical procedures that have not been performed on patents
- Unbundling, which occurs when a person is charged for individual tests even though the regulations require these tests to be bundled together
- Upcoding, which occurs when a person is billed for more expensive medical treatment or services than what they actually received
These aren’t the only types of billing fraud that occur, but they are by far the most common.
Another type of scheme that a healthcare company might use to receive false reimbursements is off-label marketing. This is technically pharmaceutical fraud, rather than medical fraud. To be guilty of off-label marketing, a pharmaceutical company must promote or market a drug for a use that has not been approved by the Food and Drug Administration (FDA). If a medication is prescribed for an off-label use, the healthcare company is not supposed to receive reimbursement from Medicaid or Medicare.
One more scheme involves healthcare kickbacks. This scheme occurs when a company makes improper payments to convince healthcare professionals to refer them to their services. For example, a pharmaceutical company paying a doctor a stipend for every referral that the doctor gives to medication manufactured by that company.
Two federal laws regard the prohibition of kickbacks. The Anti-Kickback Statute prohibits any person or company from making payments that increase patient referrals when the patient receives their healthcare coverage from a state or federal program. The Stark Law prohibits general physicians from referring patients on Medicare or Medicaid to entities with whom that physician has a financial relationship. For example, a physician referring a person to their spouse.
The interpretation of these laws can be complex. If you’ve been accused of perpetuating healthcare fraud, it’s important to get in contact with an attorney as soon as possible. The skill of a negotiator is paramount to both your future and the history of your company.
Alternatively, if you believe healthcare fraud has been committed against you, it’s important to contact an attorney to see if you have a valid case. Find skilled attorneys practiced in negotiating healthcare fraud cases on both the state and federal levels. You may be able to bring a lawsuit against the company in question, especially if other people are also able to verify that they had fraud committed against them. Don’t wait — find a lawyer as soon as you suspect the fraud has occurred.