Types of Fraud

Help us fight healthcare fraud.

Fraud and abuse costs Medicaid, Medicare and taxpayers about $120 billion per year – almost 10% of total government Medicaid and Medicare spending.

To fight this rampant fraud, the qui tam lawsuits under the False Claims Act have been used to recover billions of dollars fraudulently taken from Medicare, Medicaid, and TRICARE by healthcare schemes including:

• Medicaid/Medicare Fraudulent Billing
• Pharmaceutical Fraud
• Treatment Issues
• Misrepresentation of Credentials
• Billing for services not provided
• Upcoding or Improper Coding of Goods and Services
• Bundling and Unbundling Procedures
• Misrepresentation of Patient Date – Populations
• Billing Cap Services

MEDICAID/MEDICARE FRAUDULENT BILLING QUI TAM CASES

• Total Neglect or Failure to Provide Services – Submitting claims for services that were not provided
• Worthless Services – services that are so deficient that there was no medical value.
• Inadequate Services – denying tests or services at facilities that are paid on a per diem basis
• Standard of Care – healthcare provider fails to meet required quality of care standards
• Aggressive Treatment – ordering unnecessary medical tests and medical services
• Misrepresenting the credentials of the person who provided healthcare services

UPCODING OR IMPROPER CODING OF GOODS AND SERVICES

• Incorrectly coding healthcare services to be reimbursed at a higher rate

BUNDLING AND UNBUNDLING PROCEDURES

• Doubling Medicare reimbursements by submitting the same procedure under both bundled and unbundled service claims

MISREPRESENTATION OF PATIENT DATA – POPULATIONS

• Billing inaccuracies and false claims involving patients in nursing homes

PHARMACEUTICAL FRAUD

• Off-label marketing promoting prescription drugs for uses not approved by the FDA
• Bribing or paying kickbacks to obtain business and referrals
• Sale of adulterated medications — low quality, dangerously made, or harmful drugs