Healthcare Fraud and False Billing/Upcoding Whistleblower Attorney

doctor operating a a tablet

The healthcare system has become oppressively expensive for patients and government programs, such as Medicare, Medicaid, and Tricare. Because the commission of fraud is so widespread, whistleblowers — those who reveal the fraudulent schemes engaged at their companies — may be our best hope of uncovering, reporting, and stopping the fraud. 

Some healthcare providers, including doctors, nurses, and therapists, are being forced to engage in the fraud and threatened they will lose their job if they don’t comply. You should know that the whistleblower laws provide protections against retaliation. 

Newman & Shapiro is a Massachusetts firm with offices in Boston and Marblehead and with clients all over the country. Jeffrey A. Newman, who has an extensive background as a trial attorney, criminal prosecutor, and reporter, now focuses solely on whistleblower law. He prides himself on working to assist in the efforts of his clients to reveal corporate fraud and resolve cases successfully. 

If you are a whistleblower reporting healthcare fraud by a company or group of corrupt individuals, contact Newman & Shapiro. He knows how to assist you in achieving your goal of reporting fraudulent activity and to reap the rewards of having taken such action.

Types of Healthcare Fraud

There are several types of healthcare fraud and, unfortunately, new varieties of implementation are being put into practice all the time. This makes it all the more necessary for those who seek to enforce the law to be vigilant and those who become aware of fraudulent misconduct to report it to the authorities. Healthcare fraud includes health insurance fraud, drug fraud, and medical fraud. The culprits may be patients, doctors, hospitals, pharmaceutical companies, facilities offering physical and/or occupational therapy, urgent care centers or nursing homes.

Health insurance fraud occurs when an insurer or government healthcare program, such as Medicare or Medicaid, is defrauded by an individual or company. Under the False Claims Act, damages from fraud can be recovered by filing a qui tam lawsuit. When such damages are won in a qui tam lawsuit, the whistleblower receives a percentage (up to 30 percent) of the damages as a reward for assisting the prosecution.

Kinds of health insurance fraud include:

  • Billing for services not rendered
  • Billing for more expensive services than those actually provided (upcoding)
  • Billing for more expensive assistive devices than those actually provided
  • Duplicating claims for the same services
  • Unbundling (i.e. billing separately for services that are done performed together)
  • Billing for excessive (unnecessary) services (e.g. X-rays or MRI scans)
  • Bribing professionals with kickbacks if they submit fraudulent bills

It should be noted that kickbacks used in healthcare fraud, like kickbacks in all types of business activities, take many forms and may offer cash, jewelry, vacations, restaurant meals for participating in a fraudulent scheme. They may be used, for example, as bait to lure doctors to prescribe particular medications, so they are not only sleazy financially, but may seriously harm patients. In addition to violating the False Claims Act, such actions also violate the federal Anti-Kickback statute.

Who works on combating healthcare fraud?

Depending on the circumstances, many different individuals may be involved in fighting against the scourge of healthcare fraud. Insurance companies and law enforcement often both have investigators working to uncover fraud, and investigative teams depend on internal whistleblowers to inform them of potential targets. In order to collect evidence that will hold up in court, fraud investigators conduct surveillance and search for evidence of billing irregularities, assets that are unaccounted for, unusually high numbers of particular types of diagnostic tests or prescriptions for particular medications. When concrete evidence is discovered, the case will be referred to the appropriate state or federal law enforcement agencies for prosecution.

What qualifies you as a whistleblower?

Just having a hunch that healthcare fraud is afoot does not qualify you as a whistleblower. In order to be a true whistleblower in the eyes of the prosecution, you must:

  • Have unique, previously undisclosed information about major fraud
  • Be able to present significant details as evidence of this fraud
  • Make sure these details have been analyzed and kept secret
  • Supply information that leads to a fraud conviction

Because whistleblower evidence is considered on a “first to file” basis, time is of the essence. You must be the first to bring your case forward in order to collect the reward. 

If you’ve observed wrongdoing, please contact our office today so we can start work on your case.