Government spending on healthcare and the cost of healthcare in general has risen dramatically in the past few decades. With costs continuously escalating, the federal government has more incentive than ever before to root out the fraud and corruption in the healthcare sector that costs taxpayers billions of dollars each year.
The Medicare system represents a huge portion of government expenditure, and the work involved in simply processing claims and paying providers leaves few resources available for validating those claims. Oftentimes, Medicare simply pays the claims without much investigation into potential fraud and abuse. As a result, Medicare fraud is rampant nationwide, costing taxpayers billions of dollars in Medicare funds.
With limited funds available to investigate Medicare fraud, the federal and state governments rely on whistleblowers to report fraudulent activity. The qui tam provisions of the False Claims Act provide generous incentives and strong protections for whistleblowers who file qui tam lawsuits on the government’s behalf.
Types of Medicare and Medicaid Fraud
Nearly every part of the healthcare industry provides opportunities for unscrupulous persons and entities to defraud Medicare. Under the False Claims Act, any claim for Medicare payment that is tainted by any illegal activity or noncompliance with established regulations could potentially be considered Medicare fraud. Common types of Medicare fraud include:
While not all inaccurate Medicare billing necessarily involves intentional fraud, healthcare providers and manufacturers of drugs and medical equipment must diligently adhere to all applicable regulations to avoid potential False Claims Act violations. However, many players in the healthcare industry continue to submit false or fraudulent Medicare claims hoping to avoid detection.
It is important to keep in mind that Medicare fraud is not just stealing from the government. In many cases it also represents a public safety risk as well. Healthcare providers who act out of their financial self-interest rather than in the best interest of patients may provide substandard and unsafe treatment to patients.