Medicare and Medicaid Fraud
Medicare and Medicaid fraud means a medical provider like doctor, dentist, hospital, clinic care provider, or nursing home – makes a dishonest reimbursement claim. The most popular types of fraud include billing for unnecessary procedures or procedures that are never carrying out, for unnecessary medical tests or tests never executed; or for unneeded stuff.
What is Medicare and Medicaid fraud?
Medicare and Medicaid fraud refers to unlawful work getting biasedly high payments from government-funded medical care programs.
Medicare or Medicaid fraud cases can file to anyone who directly or indirectly causes fraud in the medical care programs.
Medicare and Medicaid frauds also include a copy in state-administered medical care programs, based on federal matching money, and because most states have now accepted local versions of the False Claims Act.
Medicare or Medicaid Fraud breaks the False Claims Act. The qui tam law provisions of the False Claims Act allow persons and organizations with proof of Medicare and Medicaid Fraud against federal programs or agreements to prosecute the offender on behalf of the United States government.
In qui tam actions, the government has the right to negotiate and join the effort. If the government rejects, the private complainant may continue on his own. Most Medicare or Medicaid False Claims Act cases also include claims under state qui tam laws modeled on the federal False Claims Act.
The Medicaid Fraud Control Units (MFCUs) work in 49 states and the District of Columbia to layout inquiries and faults related to possible fraud.
Most MFCUs work as part of the Attorney General’s office in that state and should be self-sufficient and independent from the state’s Medicaid office.
There are many types of Medicare and Medicaid fraud. Common examples include:
- Billing Medicare and Medicaid for services not provided.
- Billing for services provided to unsuitable persons.
- Damaged or illegal pricing of drugs.
- Failure to observe with “best pricing” in the Medicaid program.
- Failure to properly enroll qualified patients in a Medicaid-sponsored program.
- Nursing home mistreats and mistreats patients.
- Unlawful or unethical marketing of drugs.
- Cheating at pharmacies.
- “Off label” marketing of drugs.
- Paying kickbacks to have doctors, hospitals, or other people prescribe certain drugs or otherwise bill Medicare and Medicaid.
- Bribe to take the business.
- Bribe to get prescriptions.
- Perform irrelevant medical treatments.
- Improper referrals or self-dealing.
- Present to the federal government a false or dishonest Medicare and Medicaid claim for payment.
- Purposely using a false record or statement to get a Medicare or Medicaid claim paid by the federal government.
- Cooperate with others to get a false or fraudulent Medicare or Medicaid to claim paid by the federal government.
- Knowingly using a false record or statement to cover, avoid, or minimize a responsibility to pay money or transmit property to the federal government.
- Performing irrelevant tests or giving wrong guidelines, which is known as ping-ponging.
- Charge separately for services that are usually charging at a package rate, known as unbundling.
- Give benefits to which the patients who receive them are not allowing, using fraud, or not correctly reporting income or other financial details.
- Make repayments to illegally completed claims.
The Difficulties of Working Medicare and Medicaid Fraud
Medicare and Medicaid fraud is a multibillion-dollar exhaust on a system that is already costly to maintain. The departments that look after these programs have internal staff members observing activities for signs of fraud. In addition, some external auditors are responsible for evaluating suspicious claim patterns.
To help prevent fraud related to recognize theft, Medicare carried out a new program in 2018. Medicare associates started to receive new ID cards with a Medicare Number rather than the participant’s Social Security number.
Identifying and preventing fraud is an essential factor for the people and departments that watch these critical programs. In addition, the wasted funds lost to fraud and other illegal strategies represent resources that can use to support participants who need support.
Below are the best two examples for talking about surgeons criticized of Medicare and Medicaid fraud.
The complaint is about the University of Pittsburgh Medical Center and the head of its neurological surgery department for falsely billing Medicare and Medicaid for operations.
The complaint is about James Luketich. He is doing multiple complex surgeries simultaneously by going alternating between patients. As a result, he does not participate in critical surgeries while keeping patients under unnecessary anesthesia.
The government claims Luketich and the University of Pittsburgh Medical Center broke the rules and regulations that prevent physicians like Luketich, who make teaching services within a medical school, from billing federal health insurance programs for such surgeries. It also alleges that the practice harmed patients.
The government claimed that Luketich’s workouts have severely harmed patients by continuing their surgeries and time under anesthesia, increasing the risk of complications.
Anyway, according to the complaint, Luketich proceeded to schedule and conduct concurrent operations.
Luketich is one of UPMC’s most significant sources of income, the government said, taking in tens of millions of dollars per year. As a result, it is exploring unspecified financial losses.
Here is the second example.
Dr. Vasso Godiali is a blood vessel surgeon in Michigan who composed a $65 million medical care fraud.
Federal prosecutors charged Godiali with submitting false claims for placing stents in dialysis patients and treating arterial blood clots. The surgeon also allegedly inflated and submitted false claims to Medicare, Medicaid, Blue Cross, and Blue Shield of Michigan, ultimately driving up healthcare costs and wasting taxpayer money.
He supposedly cleaned the money through six companies and used the interests to pay estate taxes on his Houghton Lake, Michigan house.
The federal district attorney also filed a related civil claim inquiring $40 million from accounts managed by Godiali correlated to four real estate purchases.
A medical care fraud charge can bring ten years of prison time and a supreme penalty of $250,000 on any two counts. If convicted of money laundering, Godiali would serve a maximum sentence of 20 years and be fined up to twice the $49 million he allegedly laundered. He faces five counts.
Here are the top healthcare fraud takedowns of 2020.
2020 will be a historic year for medical care fraud breakdowns—more than 250 people in medical care fraud waste over $5 billion in false and fraudulent claims.
The healthcare frauds include more than 90 authorized physicians and over 25 medical care administrators. The issues also cross the normal: strategies involving products or services never provided and providers who supposedly prescribed and billed for irrelevant treatments and drugs, including anesthetics.
The following are some medical care fraud cases that happened in 2020.
Telemedicine business purchasers charged in $56M fraud conspiracy
Two telemedicine business owners were arrested for supposedly conceiving a federal medical care fraud scheme that issued over $55 million in fraudulent claims to Medicare.
Reinaldo Wilson and Jean Wilson, owners of claimed telemedicine companies Advantage Choice Care LLC and Tele Medcare LLC, were charged with paying and receiving healthcare payments and bribes to order orthotic braces for Medicare recipients.
The Wilsons reportedly carried out the scheme by hiring medical care providers to order the braces even if they were medically irrelevant, unfit for Medicare repayment.
Florida physiotherapy charged with COVID-19, healthcare fraud
Physiotherapy named Dennis Nobbe of Miami, Florida, supposedly organized a scheme to use patients through a credit card program to help them pay loan payments for medical care. Nobbe also apparently paid bribes to other physicians to open credit card retailer accounts in their names.
Furthermore, Nobbe allegedly obtained over $200,000 in Paycheck Protection Program and Economic Injury Disaster Loan (EIDL) loans intended to provide COVID-19 relief and transfer portions of the proceeds to shell companies under his control and pay personal expenses.
Feds charge ten individuals in a $1.4B rural hospital billing scheme
One of the largest healthcare fraud takedowns in 2020 involved charges against ten individuals, including hospital managers, laboratory owners, billers, and recruiters, for their claimed involvement in pass-through billing plans using rural hospitals.
The associates billed private payers approximately $1.4 billion for laboratory testing claims, out of which they paid about $400 million.
The scheme allegedly involved the takeover of small, rural hospitals and using them as a means to bill private payers for expensive urinalysis drug and blood tests that were performed mainly at outside laboratories despite claims stating they were doing in-house.
The associates also reportedly assigned higher repayment rates for tests done within the rural hospitals versus outside labs.
All defendants had charged with conspiracy to commit healthcare fraud and wire fraud.
$681M abuse treatment fraud case in Florida
Michael J. Ligotti, DO, was charged with conspiracy to commit healthcare fraud and wire fraud after allegedly engaging in fraudulent billing for tests and treatments involving patients seeking drug or alcohol addiction help.
According to the complaint, Ligotti authorized millions of dollars in medically irrelevant urinalysis tests as the owner of Whole Health in Delray Beach, Florida. Ligotti also reportedly paid bribes to mental hospitals or addiction therapy clinics to treat their patients with Whole Health providers.
The scheme resulted in $680 million in false lab testing claims. Some patients were also billed between $10,000 and $20,000 by Ligotti and Whole Health for a single day’s visit, the Justice Department stated.
Texas doctor found accusable in $325M healthcare fraud scheme
Jorge Zamora-Quezada was convicted of one count of conspiracy to act medical care fraud, seven counts of healthcare fraud, and one count of conspiracy to prevent justice after diagnosing many patients with rheumatic disease and treating them for generally toxic medicines, like chemotherapy drugs.
The Justice Department reported that his patients were as young as 12 years. Zamora-Quezada performed medical practices throughout South Texas and San Antonio.
Texas physician jailed 84 months for healthcare fraud
Physician at Texas Pain Solutions and Integra Medical Clinic got seven years in prison for his role in dishonestly billing medical care programs.
According to the evidence, Reznik Saqer would seduce weak patients to the clinics by prescribing opioids, then provide unnecessary and potentially dangerous procedures and tests using unlicensed staff.
Saqer dishonestly billed medical care providers for nearly $5 million for these services, ending in multiple patient deaths, the Justice Department reported.
In addition to the prison order, the judge also required Saqer to pay $5 million in payment.
Four doctors found wrong in $150M healthcare fraud scheme
A federal judge found four Detroit, Michigan-area doctors wrong of participating in a Medicare fraud scheme that cost the federal healthcare program $150 million.
The doctors practiced at Tri-County Group. They would charge Medicare for medically needless services, including urine tests and home healthcare. For example, the Justice Department reported that the doctors would give the following injections in exchange for prescriptions of over 6.6 million doses of medically unnecessary drugs.