Types of Fraud
There are many types of fraud that are eligible to be prosecuted under qui tam law. Some of the most common methods of fraud involve defense contractors and health care professionals providing care that is subsidized by Medicare and Medicaid.
Health Care Fraud
The following are examples of fraud in the health care industry that is covered by the False Claims Act:
- “Phantom billing” – Billing for tests not performed.
- Performing inappropriate or unnecessary procedures.
- Charging for equipment/supplies that were never ordered.
- Billing Medicare/Medicaid for new equipment while providing a patient with used equipment.
- Billing Medicare/Medicaid for expensive equipment while providing a patient with less expensive equipment.
- A drug or equipment supplier completing a Certificate of Medical Necessity (CMN) instead of the physician.
- “Reflex testing” – Automatically running a test whenever the results of some other test fall within a certain range, even though the reflex test was not requested by a physician.
- “Defective Testing” – When a test or part of a test was not performed because of technical trouble (ie: insufficient or destroyed sample, machine malfunction) but is billed to the government anyway.
- “Code jamming” – Laboratories inserting or “jamming” fake diagnosis codes to get Medicare/Medicaid coverage.
- Offering free services or supplies in exchange for your Medicare or Medicaid number.
- “Unbundling” – Using two or more Current Procedural Terminology (“CPT”) billing codes instead of one inclusive code for a defined panel where rules and regulations require “bundling” of such claims. Submitting multiple bills, in order to obtain a higher reimbursement for tests and services that were performed within a specified time period and which should have been submitted as a single bill.
- “Double billing” — charging more than once for the same service. For example, a health care provider billing using an individual code and then again as part of an automated or bundled set of tests.
- “Up-coding” – Inflating bills by using diagnosis billing codes that indicate the patient experienced medical complications and/or needed more expensive treatments. (eg., billing for complex services when only simple services were performed, billing for brand-name drugs when generic drugs were provided, listing treatment as having been for a more complicated diagnosis than was actually the case.)
- “Phantom Employees” – Expensing employees or hours worked that do not exist.
- “Improper Cost Reports” — Submitting false cost reports seeking higher Medicare reimbursements than permitted by actual facts.
- Providing substandard nursing home care and seeking Medicare reimbursement.
- Routinely waiving patient co-payments.
To protect your interests and prevent retaliation, whistleblowers should contact Ripper Law Firm PC as soon as possible.
Defense Contractor Fraud
Companies that win contracts for the United States Department of Defense are often under pressure to produce many products in a short time period. As a result, employers may ask their employees to falsify time records and other company documents to show additional hours which were supposedly spent on high-profit government projects. In other cases, defense contractors may produce defective products or substitute parts that are either inferior or from sources other than those agreed upon in the contract.
If you believe that a company is guilty of defrauding the government and there is independent evidence to support your belief, call (404) 445-5000 as soon as possible and speak with us directly.
We encourage you not to delay seeking legal representation, as a financial recovery under the qui tam law could be lost if another person brings the claim before you do.