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Through the many intricacies, nuances, and complexities of Medicare and other healthcare programs offered by the federal government, there are plenty of ways to illegally exploit these programs. There are many opportunities within the private sector to commit acts of fraud. We will take a look at some of the common ways fraud in the healthcare industry can manifest itself and connect them with current trends.
1. Upcoding.
One extremely common type of healthcare fraud is upcoding, in which healthcare providers charge for procedures that weren’t actually performed or equipment that wasn’t actually used. An example of upcoding could be billing for a certain procedure to excise a cyst when, in reality, a medical professional never excised the cyst but instead injected it to simply alleviate symptoms.
2. Unbundling.
When this occurs, it usually means that a healthcare provider has charged for services one-at-a-time instead of combining services and billing as a group. For instance, knowingly and willfully separately charging Medicare for each kind of blood test performed on a hospital patient instead of charging for the whole battery of tests at once will likely be considered fraudulent.
3. Providing gratuitous or useless medical services.
This can intersect with anti-kickback statutes and is fairly straightforward. Doctors prescribing medications or referring patients to specialists that aren’t necessary fall into this category of healthcare fraud. With the growing problem of the opioid epidemic, many plaintiffs are alleging that they were prescribed opioid medicines that were not necessary.
Healthcare Fraud Related to Opioids Will Remain Robust in 2020
The sheer magnitude of the amount of opioids prescribed to Americans in the past two decades is still coming into focus. Big pharma companies, doctors, private equity groups, and numerous other parties are being implicated. Through continued litigation on opioid abuse, even pharmacy technicians are being charged with participating in fraudulent schemes. Class-action lawsuits are being pursued by county and state governments, rather than the federal Department of Justice, against pharmaceutical companies.
Home-Health Agencies
Sometimes Medicare billing by home-health agencies is improper. Some agencies bill for unnecessary medical procedures and products that are not medically necessary because representatives know that government programs will reimburse them for costs. Therefore, it is important for home health agencies to properly document procedures in order to ensure that reimbursements and billing are executed properly.
Conclusion
Penalties are severe for those convicted of healthcare fraud. Our firm has significant experience defending clients from these types of allegations and would be honored to take on your case. Discuss your options today by calling us at 305-374-5544.
Weisberg Kainen Mark, PL
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