Healthcare fraud comes in many forms, but medical billing fraud is arguably the most widespread. Dishonest individuals and companies working in the healthcare field have devised numerous strategies for committing billing fraud against federal healthcare programs. Some of those methods include:
- Billing for services and supplies that were never rendered to the patient;
- Billing for unnecessary medical procedures;
- Upcoding, where healthcare providers bill for more expensive treatments than they actually provided;
- Billing for services provided by unsupervised mid-level providers as if those services were provided by a physician (incident-to billing);
- Billing for services provided by unlicensed clinicians who were not adequately supervised; and
- Waiving patient co-pays.
Whistleblowers in this area can be physicians, nurses, therapists, billing clerks, or even patients who observe improper billing practices. For example, in a case Newman & Shapiro attorney Jeffrey Newman brought on behalf of whistleblower Christine Martino-Fleming, mental health provider South Bay Mental Health Center paid $4 million to resolve allegations that it fraudulently billed Medicaid for mental healthcare services provided to patients by unlicensed, unqualified, and unsupervised staff members. In another recent case, Massachusetts Eye and Ear Infirmary paid over $2.6 million to resolve allegations that it improperly used the “Modifier 25” billing code to obtain higher reimbursements from Medicare and Medicaid. Similarly, in 2019, a Massachusetts physician, Hooshang Poor, paid $680,000 to resolve allegations that he submitted inflated claims to Medicare and Medicaid by assigning false procedural codes that overstated the length, extent, and scope of services he and his employees furnished to nursing home residents.