Medicare and Medicaid Fraud for Payment of Services Not Rendered

07/13/2015 // KellerGroverWB // (press release)

Medicare and Medicaid are supposed to only pay for procedures, devices and tests that were actually performed or used. Dishonest healthcare providers and organized crime have learned that with the right falsified paperwork, Medicare and Medicaid can be tricked into paying for nonexistent care and devices for fictional patients or real patients not actually cared for.

To receive payment a healthcare provider must certify the services were actually rendered and the goods were actually needed and provided. The submission of a claim for payment for health care services never provided would be a false claim and may be a violation of the False Claims Act (FCA).

The goal of the FCA is to discourage any government contractor, including a health care provider, from overcharging and falsely charging the federal government for goods or services. The law provides for civil liability of up to three times the amount of damages suffered by the government for any person who knowingly submits, or causes to be submitted, a false or fraudulent claim for payment to the Federal government. For the submission to be “knowing” the person must have actual knowledge or act in deliberate ignorance or reckless disregard of the truth or falsity of the information.

The FCA also provides for civil penalties of $5,500–$11,000 per false claim.  In healthcare fraud cases involving treatments to hundreds, and sometimes thousands, of patients these penalties can be significant.

The law’s unique  “Qui Tam” provision allows individuals to stand in place of the government and file a lawsuit against a person or entity submitting a false claim to the government. The term "Qui Tam" goes back to medieval England and became part of United States law during the Civil War as part of an effort to reduce the rampant fraud on the Union army which was routinely sold defective military supplies.

In 1986 the FCA was amended to strengthen the law and its qui tam provisions in response to massive fraud – again by defense contractors.  Since that time, the FCA has become an effective tool to fight healthcare fraud, one of the government’s largest expenditures each year.

The federal government, like all organizations, businesses and individuals, only wants to pay for services and products that were actually provided. Getting paid for actions not taken and products not supplied is fraud. Thanks to the FCA and its provision for qui tam actions, individuals can take action to stop Medicare and Medicaid fraud when dishonest individuals or organizations are paid for nothing more than fraudulent paperwork.

If you know of such fraudulent activities , contact our office to learn more about what you can do about it .

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