The charges are based on a variety of alleged fraud schemes involving various medical treatments and services, including home health care, mental health services, psychotherapy, physical and occupational therapy, durable medical equipment and pharmacy fraud.
Full Answer
What is in the Medicare fraud and abuse booklet?
This booklet provides the following tools to help protect the Medicare Program, your patients, and yourself: ● Medicare fraud and abuse examples ● Overview of fraud and abuse laws ● Government agencies and partnerships dedicated to preventing, detecting, and fighting fraud and abuse ● Resources for reporting suspected fraud and abuse
What are some examples of Medicare frauds?
It isn’t always health care providers who commit Medicare fraud, however. Additional examples of Medicare scams include: A person without Medicare coverage offering money or goods to a Medicare beneficiary in exchange for their Medicare number in order to use their Medicare benefits.
What are the laws against Medicare fraud?
In addition to Medicare Part A and Part B, Medicare Part C and Part D and Medicaid programs prohibit the fraudulent conduct addressed by these laws.
What are the benefits of Medicare fraud whistleblowing?
Federal law allows individuals reporting Medicare fraud to receive full protection from retaliation from their employer and collect up to 30% of the fines that the government collects as a result of the whistleblower's information.
The Societal Impact of Medicare Fraud
Sure, it may not seem like this is a huge problem, especially with only 15 total Strike Force cases in the news through half of 2018, but it’s important to realize that many of these investigations involve millions upon millions of dollars. Furthermore, this is money that has essentially been stolen from the U.S.
Individual Effects of Medicare Fraud
For starters, it’s simply maddening to think that individuals who commit these types of offenses are bringing in much more than the typical, hard-working family earns just to survive. For instance, Money reports that the median real income is $54,635 for households in Michigan and $57,259 for a household in Ohio.
Medicare Fraud: Protecting Yourself Begins by Protecting Your Card
According to Medicare.gov, you should always “treat your Medicare card like it’s a credit card.” In other words, don’t give the number out to just anybody, because there’s a chance it could be used to open up a fraudulent claim.
Even More Ways to Prevent Medicare Fraud
There are other things you can do to avoid being a victim of Medicare fraud.
What to do if You Are a Medicare Fraud Victim
If you believe that you are a victim of Medicare fraud or if you have unequivocal proof, the first thing you want to do is report it to the authorities. Medicare.gov shares that there are three ways to do this:
What happens if a beneficiary submits a fraudulent claim to a government-run healthcare program?
Any time a beneficiary or healthcare provider submits a fraudulent claim to a government-run healthcare program, whether intentional or not, they could face penalties of up to three times the value of that claim. In addition to fraud, both programs also have issues with waste and abuse.
Why do Medicare and Medicare fraud, waste and abuse overlap?
Because of their similarity in coverage, Medicare and Medicare fraud, waste and abuse (FWA) schemes often overlap. For example, either program could be defrauded by:
What is healthcare fraud?
One of the most horrifying healthcare fraud schemes in the US involves fraudulent drug treatment centers and sober homes. Rather than helping people recover from addiction, these facilities defraud Medicaid and Medicare in a variety of ways.
What is medical identity theft?
Medical identity theft. Selling or giving a duplicate Medicare or Medicaid ID card to someone else. Sharing an ID card. Submitting false information in order to qualify for coverage. Both Medicare and Medicaid fraud schemes violate the Federal Civil False Claims Act (FCA).
How many medical records were breached in 2016?
In 2016, 27 million medical records were breached —that equates to 10 per cent of the US population. Stealing medical data is one of the most attractive healthcare fraud schemes for criminals for a number of reasons. Fraudsters who steal Medicare and Medicaid information may want it for personal use.
What is DME fraud?
Durable Medical Equipment (DME) Fraud. Durable medical equipment (DME) includes healthcare equipment and supplies, including wheelchairs, crutches, hospital beds, oxygen equipment and diabetic testing supplies. This equipment can be expensive, especially for beneficiaries who need it for the long term and/or are on a limited income.
What is Medicare Part A?
Medicare Part A covers hospital and inpatient services, while Part B covers outpatient medical treatments and supplies. Together, they make lab tests, doctor visits, preventive services and hospital stays affordable for beneficiaries. Unfortunately, both are common targets for fraud.
Which Medicare programs prohibit fraudulent conduct?
In addition to Medicare Part A and Part B, Medicare Part C and Part D and Medicaid programs prohibit the fraudulent conduct addressed by
What is Medicare abuse?
Abuse includes any practice that does not provide patients with medically necessary services or meet professionally recognized standards of care.
What is the role of third party payers in healthcare?
The U.S. health care system relies heavily on third-party payers to pay the majority of medical bills on behalf of patients . When the Federal Government covers items or services rendered to Medicare and Medicaid beneficiaries, the Federal fraud and abuse laws apply. Many similar State fraud and abuse laws apply to your provision of care under state-financed programs and to private-pay patients.
What is the OIG hotline?
The Office of Inspector General (OIG) Hotline accepts tips and complaints from all sources on potential fraud, waste, and abuse. View instructional videos about the
Why do doctors work for Medicare?
Most physicians try to work ethically, provide high-quality patient medical care, and submit proper claims. Trust is core to the physician-patient relationship. Medicare also places enormous trust in physicians. Medicare and other Federal health care programs rely on physicians’ medical judgment to treat patients with appropriate, medically necessary services, and to submit accurate claims for Medicare-covered health care items and services.
What is heat in Medicare?
The DOJ, OIG, and HHS established HEAT to build and strengthen existing programs combatting Medicare fraud while investing new resources and technology to prevent and detect fraud and abuse . HEAT expanded the DOJ-HHS Medicare Fraud Strike Force, which targets emerging or migrating fraud schemes, including fraud by criminals masquerading as health care providers or suppliers.
Is there a measure of fraud in health care?
Although no precise measure of health care fraud exists, those who exploit Federal health care programs can cost taxpayers billions of dollars while putting beneficiaries’ health and welfare at risk. The impact of these losses and risks magnifies as Medicare continues to serve a growing number of beneficiaries.
How much money does the government lose from medical billing scams?
Medical billing experts estimate that the US Government loses 30 cents of every dollar earned from fraudulent practices and medical billing scams. With confusing Medicare regulations spanning over 45,000 pages, an endless supply of loopholes and technicalities susceptible to illegal utilization, and the average person’s inability to wade through a mountain of paperwork and medical jargon, it’s no wonder that people and the government alike lose thousands each year to medical billing fraud. Here are five of the most common types of medical billing fraud and how to avoid them.
How does fraud affect health insurance?
Not only does this type of fraud take a massive financial toll on the government, but it can affect a patient’s health insurance as well. Fraudulent claims for procedures that never happened still show up on the patient’s medical report and can therefore affect their insurance or the way future doctors treat them.
What is Phantom Billing?
Phantom Billing. “One of the most common types of Billing fraud has to do with services being billed that were not actually performed. This type of fraud impacts the cost of health care because it drives up the cost by the mere fact that the charges are not justified but there are also millions of dollars spent each year tracking ...
How much did the University of Texas Southwestern Medical Center settle for Medicare?
In September 2011, The University of Texas Southwestern Medical Center at Dallas paid a $1.4 million settlement to resolve allegations of upcoding of Medicare and Medicaid claims.
What is upcoding in medical billing?
This fraudulent practice has been coined as “upcoding,” since your doctor or healthcare provider must attach a CPT (current procedural terminology) code to each procedure performed — and that code dictates how large or small the subsequent bill will be. Since its often large insurance companies who are processing thousands of computerized bills on a regular basis, many improperly coded procedures are easily overlooked.
What is unbundling in billing?
Unbundling happens when multiple procedures meant to be billed in a package deal are billed separately, therefore creating a higher invoice.
Why is it important to review medical bills?
It’s important for all patients to rigorously review all of their medical bills for mistakes, overcharges, and double-charges. All patients have the right to an itemized bill and can request one from the hospital where they were seen.
What are the most common forms of medical billing fraud?
Medical billing fraud can occur in a variety of ways. Some of the most common ones are upcoding, unbundling, and billing for services that were not provided . Many other fraudulent schemes exist, however.
What is upcoding in Medicare?
Upcoding also occurs with risk adjustment fraud committed under Medicare Part C, when a Medicare Advantage patient’s diagnostic data is exaggerated in order to draw additional risk adjustment payments from Medicare.
What is upcoding fraud?
Upcoding is a kind of medical billing fraud that occurs when a provider sends a bill to Medicare or another payor for a more expensive service than the one actually performed. For example, the provider might: exaggerate the time the procedure took to perform.
What is unbundling billing?
Unbundling is a fraudulent billing scheme accomplished by billing several different procedure codes for a group of procedures, even though the group should properly be billed under a single all-encompassing code.
What is bill for therapy?
bill for individual therapy when group therapy was actually provided. simply make up that a procedure happened. perform (and bill for) procedures that patients simply do not need in violation of “medical necessity” rules.
Does the government pay for medical services?
The Government will only pay for medical services that are actually performed or for equipment that is actually delivered. It can be a violation of the False Claims Act to bill the Government for healthcare services, supplies or equipment that were not performed or delivered.
Is a provider liable for a fraudulent bill?
Many other fraudulent schemes exist, however. When a provider submits a fraudulent bill for payment, they may be liable under the False Claims Act, and whistleblowers pay a critical role in exposing this kind of fraud.
How many doctors were charged with Medicare fraud?
Attorney General Eric Holder and Department of Health and Human Services (HHS) Secretary Kathleen Sebelius announced today that a nationwide takedown by Medicare Fraud Strike Force operations in six cities has resulted in charges against 90 individuals, including 27 doctors, nurses and other medical professionals, for their alleged participation in Medicare fraud schemes involving approximately $260 million in false billings.
Who is investigating Medicare fraud?
The cases announced today are being prosecuted and investigated by Medicare Fraud Strike Force teams comprised of attorneys from the Fraud Section of the Justice Department’s Criminal Division and from the U.S. Attorney’s Offices for the Southern District of Florida , the Eastern District of Michigan, the Eastern District of New York, the Southern District of Texas, the Central District of California, the Middle District of Louisiana, the Northern District of Illinois and the Middle District of Florida; and agents from the FBI, HHS-OIG and state Medicaid Fraud Control Units.
How much was the Detroit fraud case?
In Detroit, seven defendants were charged for their roles in fraud schemes involving approximately $30 million in false claims for medically unnecessary services, including home health services, psychotherapy and infusion therapy. In one case, four individuals, including a doctor, were charged in a sophisticated $28 million fraud scheme, where the physician billed for expensive tests, physical therapy and injections that were not necessary and not provided. Court documents allege that when the physician’s billings raised red flags, he was put on payment review by Medicare. He was allegedly able to continue his scheme and evade detection by continuing to bill using the billing information of other Medicare providers, sometimes without their knowledge.
How many people were charged with the Houston Medicare Strike?
Eleven individuals were charged by the Houston Medicare Strike Force. Five Houston-area physicians were charged with conspiring to bill Medicare for medically unnecessary home health services. According to court documents, the defendant doctors were paid by two co-conspirators to sign off on home health care services that were not necessary and often never provided.
Is CMS working with law enforcement?
and CMS is committed to working with our law enforcement partners to get criminals behind bars and out of the Medicare program as swiftly as possible,” said CMS Program Integrity Deputy Administrator Agrawal. “Today’s actions represent further consequences for bad actors, many of whom CMS had already stopped paying, or even kicked out of the program. Fundamentally, this is about protecting the well-being of our beneficiaries and the investment of taxpayer dollars.”
What is the second most costly type of fraudulent disbursement scheme?
18. According to the 2010 Report to the Nations on Occupational Fraud and Abuse, billing schemes were the second most costly type of fraudulent disbursements schemes.
Who stole $50,000 from Valdosta Medical Supply?
Charles Dieter and Joey Davis worked together to steal nearly $50,000 from Valdosta Medical Supply. Charles, an accounts payable clerk, deliberately overpaid a few of the company's vendors. He then called the vendors, explained the "mistake," and asked for the excess to be refunded.
Why is Medicare fraud so hard to track?
The total amount of Medicare fraud is difficult to track, because not all fraud is detected and not all suspicious claims turn out to be fraudulent. According to the Office of Management ...
How much money did the government give to fight Medicare fraud?
In 1997, the federal government dedicated $100 million to federal law enforcement to combat Medicare fraud. That money pays over 400 FBI agents who investigate Medicare fraud claims.
What is the Office of Investigations for the HHS?
The Office of Investigations for the HHS, OIG collaboratively works with the Federal Bureau of Investigation in order to combat Medicare Fraud. Defendants convicted of Medicare fraud face stiff penalties according to the Federal Sentencing Guidelines and disbarment from HHS programs.
What is a patient billing scam?
Patient billing: A patient who is in on the scam provides his or her Medicare number in exchange for kickbacks. The provider bills Medicare for any reason and the patient is told to admit that he or she indeed received the medical treatment.
What is Phantom Billing?
Phantom billing: The medical provider bills Medicare for unnecessary procedures, or procedures that are never performed; for unnecessary medical tests or tests never performed; for unnecessary equipment; or equipment that is billed as new but is , in fact, used.
How much did whistleblowers contribute to civil settlements?
According to US Department of Justice figures, whistleblower activities contributed to over $13 billion in total civil settlements in over 3,660 cases stemming from Medicare fraud in the 20-year period from 1987 to 2007.
How much money has the False Claims Act recovered?
The Justice Department has used the False Claims Act to recover more than $7.7 billion from January 2009 to June 2012 in cases involving fraud against federal health care programs.