Medicare/Medicaid Fraud

Medicare / Medicaid Fraud
Healthcare fraud on the federal and state governments mainly involves cheating Medicare and Medicaid by submitting false billing and receiving payment from the government. One of the problems is that when the Medicare program was set up in 1965 as part of the Social Security Act, the government created and honor system for billing in which invoices submitted for payment of healthcare services were assumed to be fair, honest and accurate. The government officials just thought that doctors and other healthcare providers just wouldn’t cheat. Unfortunately, this is just not the case.

“Medicare is being plundered for hundreds of millions of dollars each year and that money comes from the taxpayers wallet.”

 

 

Now, Congress has finally realized how widespread the fraud is and has enhanced the whistleblower laws allowing for individuals with information about the fraud to collect a portion of the governmental recovery. Major whistleblower cases have successfully be engaged against hospitals, nursing homes, skilled nursing facilities, home health agencies, pharmacies, HMO’s and physicians groups. In these cases, the fraud which has been uncovered has been clear and extensive and in some cases individuals have gone to jail for it.

Healthcare Fraud: The Types of Cases Accepted by the Firm

Healthcare Fraud is a major problem in the United States. However, not every instance of fraud can lead to a case. Jeff Newman reviews scores of cases each year and looks for evidence of systemic fraud, not just a lone rogue employee stealing moneys. There must be a business scheme from the top of the company and a clear pattern of company-wide wrongdoing. A whistleblower must reveal new information which has not been publicly disclosed previously.

 

Hospice Care Fraud

Hospice is a program of care and support for people who are terminally ill. Its goal is to help people who are terminally ill live comfortably and the focus is on comfort and not curing an illness. The services include physical care, counseling, drugs and supplies and it is usually provided at home. Medicare hospice benefits are available if a person is a) eligible under Medicare Part A (hospital insurance); a doctor and the hospice medical director certifies that a person is terminally ill and has 6 months or less to live; care is provided by a Medicare approved hospice program.

Example of Hospice Care Fraud: There have been many instances of hospice care fraud over the last couple of years. One whistleblower lawsuit was filed against a company called VistaCare Hospice in which the company paid enrollment bonuses to doctors, admissions directors and branch managers, according to whistleblower Misty Wall, a former social worker for the company. This March Odyssey Healthcare Inc. one of the nation’s largest providers of hospice care agreed to may $25 million to settle a Medicare fraud whistleblower case filed by a former company nurse. Jane Tuchalski the RN whistleblower said that the company submitted false claims to the Medicare program through a systematic pattern and practice of enrolling and re-certifying non terminal patients; billing for continuous care when that was not reasonable or necessary. The whistleblower recovered about $5 million, 20% of what the government collected which is part of The False Claims Act law.

  Skilled Nursing Facility Fraud

 

Hospice is a program of care and support for people who are terminally ill. Its goal is to help people who are terminally ill live comfortably and the focus is on comfort and not curing an illness. The services include physical care, counseling, drugs and supplies and it is usually provided at home. Medicare hospice benefits are available if a person is a) eligible under Medicare Part A (hospital insurance); a doctor and the hospice medical director certifies that a person is terminally ill and has 6 months or less to live; care is provided by a Medicare approved hospice program.

Other accepted Healthcare Cases include:

  • Billing for services not rendered or products not delivered
  • Billing for services or supplies not ordered
  • Billing for unnecessary services, including furnishing services in excecss of patient’s needs.
  • RUG upcoding