You and Fraud

What can you do about medical fraud? Actually, many things, it is up to people , ordinary people to stop fraud, by doing so you help people to not become victims, you help to stop the high cost of insurance, stop taxpayers dollars from being wasted, and improve the health care system!!!!
Share in the recovery
On top of this, if you are the first one to report fraud , you can be entitled to a percentage of the money that is recovered!! Often times this is 25 percent of the recovered amount! some examples,
will receive $1.75 million as his share ( florida April 14, 2008 )
will receive $1,020,000 as his statutory share of the proceeds ( california march, 2009 )
. Dr. Tiesinga will receive $300,000 as his share of the proceeds of the settlement ( washington 2007)
, will receive $412,500 as her share of the settlement ( Illinois 2008 )

Not to even mention that you will be doing a world of good.
There were many companies out there that had someone in the inside, or someone who used the company and knew of illicit goings on, had reported them, then they could have stopped the company from going bankrupt, stopped them from losing employee retirements etc.
Is it your ethical duty?
In a nutshell, yes. People are harmed by fraudulant acts, if it is overbilling they are harmed by higher costs of insurance, or taxes if medicare is over billed, if it is by opthamologists performing unwarranted surgeries, you can save patients harm, there are many ways it helps to put a stop to fraud or abuse!
How can you help?
Here are a few law firms that take cases, I do not have any connection to any of these.
Toll Free 1 (888) 482-6825
Tel: 202.833.4567212) 376-5666 1-888-933-1514
1-888-775-3779
Attorney General Conway Announces Optometrist Indictment ( kentucky )
Citizens are urged to report suspected fraud or elder abuse by calling the Attorney General’s tip line at 1-877-ABUSE TIP (1-877-228-7384).

What kinds of fraud to look for ? some examples are.


Services not rendered
Upcoding schemes and Unbundling
Kickbacks and Self Referrals
Falsely Certifying and Giving False Information
Lack of Medical Necessity
Fraudulent Cost Reports
Grant or Research Fraud


SERVICES NOT RENDERED:
The simplest scheme of healthcare fraud is the billing for services that were never rendered to patients.
Examples under this scheme include healthcare providers billing Medicare or Medicaid for services that were never performed, medical supplies and equipment that were never delivered, and lab or medical tests that never occurred.
UPCODING AND UNBUNDLING:
Upcoding
Another common scheme involves upcoding to obtain a higher reimbursement than one is entitled to. Medicare and Medicaid systems use a set of billing codes which healthcare providers use in billing for services. These codes are known as the HCPCS codes. In an upcoding scheme, providers wrongfully use a higher paying code to fraudulently reflect that a more expensive procedure or device was involved in the patient’s treatment. These codes are billed electronically and typically slip through the system unless caught through a random audit of only approximately 2% of the claims each year. The only other way to catch the fraudulent use of these higher codes is for an insider to come forward and report the upcoding.
Unbundling
Another common example of coding fraud is called "unbundling." When procedures or lab tests involve a number of related services or tests that are typically performed together, Medicare and Medicaid have specific billing codes that must be used to obtain reimbursement for all of the associated services or tests as a whole, rather than allowing reimbursement for each of the related services or tests billed separately.
KICKBACKS:
A federal statute known as The Stark Law, is designed to prevent billing for Medicare services resulting from abusive self-referrals and kickbacks. Under the Stark Law, a physician is prohibited from making any referral to a provider of designated health services if the physician has a "financial relationship" with the provider, unless an exception applies.
Examples
an HMO provider had come under increasing pressure to switch from an equally effective but significantly less expensive alternative drug because the pharmaceutical company offered its doctors a panoply of inducements to prescribe the expensive drug, including ski and golfing trips, free televisions and VCRs, cocktail party bar tabs, and an array of free products and services.
FALSE CERTIFICATIONS AND INFORMATION:
Health care providers are required to act openly and honestly with the Medicare and Medicaid programs and submit claims based upon accurate information. In addition, Medicare providers are required to disclose all known errors and omissions in their claims for Medicare reimbursement. Providers who submit false claims in violation of these requirements violate the False Claims Act.
Examples
In Mississippi, a hospital chain agreed to a $1.5 million settlement of a qui tam lawsuit in which it was alleged that the hospital billed under physician provider numbers when, in fact, the services were rendered by nurses rather than physicians.
LACK OF MEDICAL NECESSITY:
It is improper to bill Medicare for services or treatment that is not medically necessary. To knowingly do so is a violation of the False Claims Act.
Examples
In New York, an ophthalmologist agreed to pay a settlement of $8.5 million for performing medically unnecessary, contraindicated, and unperformed ophthalmologic services. The settlement agreement provided that the doctor would be permanently excluded from all federally funded health care programs. The physician’s own medical charts did not justify the wide scope of services for which he submitted bills. He also created and submitted new documentation, sometimes years after the questioned dates of service, to attempt to justify his claims after Medicare requested supporting documentation.
In Illinois, a physician group filed false claims for reimbursement to Medicare and Medicaid by submitting claims for inpatient services that were not supported by sufficient documentary evidence and filed claims for both inpatient and outpatient services that were wrongly coded. The physician group agreed to pay an $8.275 million settlement.
An optometrist billing for the comprehensive eye exam when he or she performed the lower level exam
An ophthalmologist falsifying documentation for a test that is used to establish the need for cataract surgery


Audits by the Office of the Inspector General reveal that $1 out of every $7 spent on
Medicare and Medicaid is lost due to fraud and abuse. This problem affects everyone.
It affects those who depend on these programs by diminishing the quality of treatment
they receive. It affects families and caregivers by decreasing the funding available for
important health care support. It affects all taxpayers by wasting billions of dollars per
year.