False Claim Examples
Either individuals or groups of healthcare workers can participate in healthcare fraud. They misrepresent their services and overcharge the federal government. According to the U.S. Department of Justice, there are a few examples of healthcare fraud to be aware of.
1. Billing for Services or Goods Not Provided
A healthcare worker cannot submit a claim for a medical service that he or she did not perform. A claim may also not be submitted for tests that were not run, devices that were not used, and drugs that were not prescribed. Fines for these false claims can reach up to three times the government program’s loss.
Example: John has Medicaid. He goes to the doctor for an infection, where he receives a single diagnostic test. The doctor, however, submits a claim to Medicaid claiming that John also received other diagnostic tests that were not actually administered. Under the FCA, the doctor is fined for each test not performed.
2. Falsifying Medical Certificates and Billing for Unnecessary Services
By law, a medical professional cannot bill federal insurance companies for unnecessary medical procedures. If a doctor bills the government after performing an exam or prescribing medicine that a patient did not need, he or she could face false claim charges.
3. Billing Separately for Services
Some services need to be combined when it comes to billing. Some doctors try to defraud the government by separating the bills for multiple services that usually fall under one package.
Example: Howard visits the doctor to undergo a procedure on his knee. This type of procedure involves a few different operations, all of which fall under one package. However, the doctor decides to bill the operations separately to make them look like separate procedures, instead of components of a single procedure. The doctor is fined for defrauding the government.
4. Falsifying Treatment Plans or Medical Records
If a healthcare professional creates fake documents to validate false claims, then he or she may face severe charges. These charges would fall under the criminal component of the FCA.
Example: Doctor Adams creates a false medical record for a patient, Susie, claiming that she has severe psoriasis. He uses this fake record to prescribe unnecessary steroids and perform unnecessary procedures. However, when Susie goes to another doctor for a second opinion, the doctor discovers Doctor Adams’ falsified medical records and treatment plan. Apparently, Susie only has a mild rash, not severe psoriasis. As a result, Doctor Adams faces criminal charges.
5. Misrepresenting Diagnoses or Procedures
A doctor might misrepresent a patient’s diagnosis, making it look more serious than it really is. This would increase the return they get from the federal health insurance provider.
6. Misrepresenting Charges
This method of fraud is similar to billing the government for goods or services that were not provided. Here, however, a doctor falsifies their entitlements to reimbursements.
7. Receiving “Kickbacks” for Providing Goods or Services
Under federal law, physicians are not allowed to receive “kickbacks” for referring patients to federal health programs. Kickbacks might include money or any asset of value. An example of this would be a physician recommending that one of their patients goes to a practice that bills their services to Medicaid. That practice pays the physician for referring the patient. This behavior is illegal, and healthcare fraud.
Example: Janie goes to Dr. Howe about pain in her back. Though Dr. Howe knows how to treat Janie’s back, he recommends that she visit another physician across town, Dr. Vasquez. He tells her that Dr. Vasquez accepts Medicare, presenting this as a positive. When Janie becomes a patient of Dr. Vasquez, Dr. Howe receives a “thank you” payment from Dr. Vasquez. This money is a kickback and is illegal under the FCA.
Summary
A healthcare practitioner that attempts to defraud the government by falsifying claims can be reported by colleagues or patients. Depending on the violation, punishments and fines can be severe. If a medical practitioner is facing consequences related to the FCA, he or she should contact a lawyer for legal representation.
