Medicare Billing Fraud

For the last 25 years, the most frequently filed qui tam cases have been in the healthcare area. In fact, $3 billion was recovered in healthcare cases in Fiscal Year 2012 alone. Many of the best qui tam cases concern Medicare Billing Fraud by providers of healthcare services to senior citizens and disabled persons, as well as billing fraud in other Government healthcare insurance programs, such as Medicaid (for indigent people) and Tricare (for US service men, women and families) and Champus (Tricare's predecessor). Typically, the cases are brought by healthcare employees, sales representatives, consultants, competitors, and even patients or their families. The defendants have been hospitals and healthcare systems, skilled nursing facilities (SNFs) and nursing homes, hospices, pharmaceutical companies and pharmacies, durable medical equipment (DMEs) manufacturers, and doctors and physician practice groups. The cases involve allegations of Medicare Billing Fraud for reimbursements under Medicare Part A (hospital and institutional inpatient care), Medicare Part B (physician services and outpatient care), Part C (Medicare Advantage managed care) and Medicare Part D (prescription drugs).

Medicare Billing Fraud

1. What types of conduct constitute Medicare Billing Fraud?

If a healthcare provider is seeking payment for a service or product and knowingly doesn’t deserve to get paid as much as requested or even paid at all, it is likely the provider is committing Medicare Billing Fraud. Examples include: billing for services not rendered; upcoding diagnoses and procedures; using non-credentialed providers; providing medically unnecessary services and goods; falsifying certificates of medical necessity; violating HHS/CMS regulations and policies; paying kickbacks; making improper referrals; engaging in accounting and Cost Report fraud; promoting pharmaceutical off-label marketing; and providing substandard care.

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2. What is a “claim” for reimbursement and do I have to have the actual invoices?

A “claim” under the False Claims Act is usually an invoice, bill or other written request for payment or reimbursement that is submitted to a Medicare contractor for payment. For Medicare Billing Fraud the actual claim form for Part A is typically the CMS Form UB-04 or UB-092 and/or the Cost Report. For Part B it is the Form 1500. For prescription drug cases it is the Pharmacy Reimbursement Claim Form. For DME cases the key form is often the Certificate of Medical Necessity (CMNs).

Some courts in certain geographic jurisdictions require you to have at least one representative claim form (or its details); while other courts require only that you have good reason to believe that such claim forms were presented for payment. This is a complex legal issue that needs to be addressed on an individual basis.

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