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 health care fraud schemes investigated by the DOJ.
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.
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.
Allowing Staff to Perform Medical Examinations
The Medicare and Medicaid billing rules require physicians to perform certain procedures—not nurses or other medical staff. 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.
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.
Contact 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. Please contact us as soon as possible to schedule a free consultation.