Health care fraud can take many forms, but there are common types of health care fraud schemes frequently prosecuted by the Department of Justice (“DOJ”). It is also a frequent subject of False Claims Act (“FCA”) qui tam suits. FCA actions have resulted in the recovery of billions of dollars on behalf of taxpayers. In this article, we discuss the most common healthcare fraud schemes investigated by the DOJ. These cases often involve allegations of improper billing practices or the submission of false claims to government programs and private insurance companies. At their core, many investigations focus on whether providers accurately documented and billed for the services they performed.
Federal enforcement initiatives, such as the DOJ-led National Health Care Anti-Fraud efforts, actively target these fraud schemes. Because of this heightened scrutiny, health care providers and administrators must follow strict billing, regulatory, and documentation requirements.
Medically Unnecessary Services
Medicare and Medicaid only provide reimbursement for procedures or expenses that are medically necessary. When medical professionals suggest procedures, tests, and other medical processes that aren’t medically necessary, this is considered to be a type of fraud. These allegations often arise when providers submit bills for services that aren’t properly justified or don’t meet accepted standards of care. In many cases, the issue comes down to whether the treatment was truly necessary.
Poor documentation, incomplete medical records, or pressure to increase revenue can attract government scrutiny. Even when providers believe they’re acting in a patient’s best interests, billing for medically unnecessary medical procedures can result in serious civil and criminal penalties.
Kickback Schemes
A kickback is an arrangement made between providers in which one party unlawfully refers patients to another party. Kickbacks can be in the form of cash, gifts, free or discounted services or supplies, travel, and anything else that has monetary value. The DOJ is particularly focused on whether kickbacks impact medical decision-making. These fraud schemes are prohibited under the federal Anti-Kickback Statute and often involve improper financial relationships with laboratories, pharmaceutical companies, and medical device manufacturers. In simple terms, providers cannot accept payments or incentives in exchange for patient referrals.
Problems come up when medical decisions are driven by financial gain rather than patient need. When referrals are tied to compensation, providers and organizations may face serious civil and criminal penalties.
Allowing Staff to Perform Medical Examinations
The Medicare and Medicaid billing rules require physicians, not nurses or other medical staff, to perform certain procedures. However, it is becoming common for providers to allow nurses or office staff to handle routine procedures while billing for the cost of the physician’s time to perform the work. Not only can this be a form of fraud if not performed under specific circumstances, but it can also present a danger to patients. Providers who violate these rules may place patients at risk by allowing inexperienced or undertrained staff members to perform certain medical procedures. Conduct like this might also involve falsified documentation or inaccurate medical records, which can expose providers to audits and federal investigations.
Upcoding
Finally, upcoding is probably the most common type of fraud. Upcoding involves billing for one service when a less expensive service was actually provided or billing for services that were never rendered. These practices frequently involve submitting inflated claims to Medicare, Medicaid, or private insurance companies.
Even unintentional coding errors can raise red flags during an audit. But when investigators believe a provider knowingly submitted false bills for services, the stakes rise quickly. Penalties may include steep fines, exclusion from federal health care programs, and even criminal charges.
Talk to a Health Care Fraud Attorney
If you’ve been accused of health care fraud, you need an experienced health care fraud defense attorney on your side. At Griffin Durham Tanner & Clarkson LLC, our attorneys understand the inner workings of fraud investigations.
We are well-prepared to defend you against investigations, audits, grand jury proceedings, FCA investigations, Controlled Substances Act diversion investigations, misbranding investigations, and the entire range of charges. In addition, our attorneys work nationwide, meaning that we are available to defend you against charges no matter where you reside in the United States. When you choose us to represent you in your case, we will work tirelessly to protect your rights and your reputation.
Our firm represents clients nationwide from offices in Atlanta and Savannah. You can reach us at (404) 891-9150 in Atlanta or (912) 867-9140 in Savannah. Give us a call or contact us online to discuss your situation.
