Healthcare Fraud Lawyer

There are several different cases that involve healthcare fraud. It is important to understand that healthcare fraud does not only happen in hospitals. It can happen anywhere the government pays for any type of healthcare service. If you have reported illegal activity in the healthcare field, contact a dedicated whistleblower attorney. A seasoned healthcare fraud lawyer could protect your rights.


Kickbacks are an essential area of False Claims Act law, especially with regard to medical services because there is a law called the anti-kickback statute. This statute creates liability for anyone who either provides an illegal inducement to anyone to receive government healthcare, to refer someone to get government healthcare, to arrange for an individual to get government healthcare or someone who receives such an inducement in order to do any of those things. Violating the anti-kickback statute is illegal. Anytime a whistleblower can show illegal remuneration to induce government-sponsored healthcare, it creates a strong possibility of a successful False Claims Act.

Services Not Rendered

It may seem obvious but any time providers charge the government for healthcare services, they actually have to provide those services. They cannot legally charge under a government insurance program and for that matter private insurance too for services that are not actually rendered. There can be variations such as double billing when a claim is submitted twice for the same service and they did not provide the service the second time. Billing for a service that one did not provide is fraud under the False Claims Act.

Upcoding Services

All government programs operate on a billing system that uses codes to bill government programs for services. The codes usually go from one to five depending on the complexity of the case. Much of Medicare, Medicaid, and healthcare billing is done using codes. This is how the procedure to bill under Medicare and Medicaid is conducted, either by a form that is sent in or electronically. The procedure provided to the patient is coded and those codes usually go on a range for whatever service was provided. From one-to-five with one being the least complicated to the most complicated, and up-coding has become the shorthand term used by everyone to describe the practice of charging for a more expensive version of service than is actually provided.

There has to be some documentation of the case and these cases come down to situations in which someone has somehow enforced a systematic way to charge a more expensive code and not charge the least expensive code. Upcoding is essentially charging for an expensive service when the minimal service is actually provided.

Bundling and Unbundling Bills

Unbundling and bundling refer to the billing which is supposed to include some medical procedures as part of others. In all kinds of procedures, there can be a lesser included service within a service, and this kind of activity usually requires that the biller charges for the more expensive service so as to include the lesser service. If a provider unbundles them and charges them separately, they get more money. Unbundling bills can be difficult to catch because the service is actually provided. Contact a healthcare fraud attorney to learn more.

Lack of Medical Necessity

Medical necessity is the basic requirement for any service to be provided under a government healthcare program. It is so basic to health care coverage that it may be required under private insurance plans before they are going to pay as well. In any case, the government claims it does not pay for medical services that are not deemed to be medically necessary.

The doctor’s opinion with respect to medical necessity carries some considerable weight. Most of the time if the doctor prescribes something or if the doctor orders something, it is medically necessary. The Center for Medicare and Medicaid Services does not have the resources to follow every patient around and make sure that the services being provided are medically necessary. However, many times, lab tests are altered, required readings are skipped, required diagnoses are just wrongfully claimed and/or providers find a way around truthfully establishing medical necessity, or they lie about medical necessity in order to go ahead and provide an unneeded service and, consequently, bill the government.

False Certification

There are generally two kinds of false certification liability. There is express false certification, someone lies on a form directly either on a form they submit to the government to bill, or they propose a form to submit to the government to obtain a contract or to qualify the bill. Implied false certification is one of the most litigated and important areas of False Claims Act law because it derives from the common-sense idea that billers are supposed to tell the truth when charging the government and when they sell something to the government.

Research Grant Fraud

There is a substantial amount of government funds provided to people and institutions to conduct research in science, in medicine, and in defense for example. Those funds come attached with requirements for the researchers to fulfill. If they lie about the type of research they are doing or what they are using funds for, or for example, they file a paper and they take the money and go and put it in their private bank account, yet they do not do any actual research well these types of activities can create a case and have actually occurred.

The government does not necessarily have time to have a continual relationship with the grant fund receiver and follow everything that they are doing. They are supposed to submit documentation to show the research they have done and show that the funds were used properly.

Improper Financial Interest

Healthcare fraud lawyers see improper financial interest as probably being the most serious in terms of a False Claims Act case under Stark law. Stark law is a complicated area in itself, but the concept is that physicians who have a financial interest in an entity should not be able to refer to that entity for certain types of healthcare services. It is not so much that the financial relationship itself is improper in this case, it is more that the physician is referring to an entity in which they have an interest.

Inflating Cost Reports

There is much government contracting that is based on the cost incurred by the contractor with certain performance goals and certain bonuses and maybe some percentage on top of that. To that extent, to the degree that a contractor can artificially inflate the cost of performing the contract either by paying too much to subcontractors, adding expenses that are supposed to be overhead but are not and direct costs to the government, it is possible for contractors to inflate a cost report and defraud the government.

Medicare Part D Fraud

Medicare Part D is a prescription drug benefit, and it is optional. The recipient pays a copay and they get prescription drug benefits. It helps cover the cost of prescription drugs which are obviously really expensive to most people who need them. There are all kinds of issues with copays: when it kicks in and how much, but Medicare Part D is a big benefit because Medicare-eligible patients are by definition 65 and older, so they may need a long list of prescription drugs, and therefore use many prescription drugs and use the benefit extensively. It is a large market for the pharmaceutical industry and therefore, creates more of an opportunity for fraud.

Contact a Healthcare Fraud Attorney

Whistleblower attorneys could help individuals determine the viability, and the value, of a case and help protect the rights of the whistleblower. A healthcare fraud lawyer could advise whether the whistleblower may or may not have a great case under one whistleblower law and steer them to other ways of dealing with the facts. In any event, the activity involved in whistleblowing and reporting information to the government is serious. Call today to schedule a consultation with a seasoned legal professional.

Healthcare Fraud Lawyer