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False Claims Act and Health Care Fraud

Health care fraud is a serious problem in the U.S., with costs that can reach an estimated $100 billion annually. Health care fraud has become so significant that the U.S. Department of Justice has established a Health Care Fraud Unit with the sole focus of addressing the problem and its ramifications.

Health care fraud comes in different varieties. An example of one form of fraud that resulted in a ten-year prison sentence, involved an acupuncture clinic making false claims for physical therapy treatment as acupuncture is not covered by Medicare. In another case, a nursing home was ordered to repay tens of thousands of dollars, and several employees faced criminal charges, after providing unnecessary treatments to residents.

The False Claims Act (FCA) is a tool that the government uses to deal with health care fraud cases and one that also allows private citizens to get involved. Read on to learn more about the FCA and health care fraud and where to go for help.

What is the False Claims Act?

The FCA is the big stick that the federal government uses against those who file fraudulent claims against it, especially those related to health care. With penalties upwards of $10,000 for each false claim in addition to three times the actual damages suffered by the federal government (three times the amount of the false claim), the Act can be quite effective.

One of the other important aspects of FCA is that which allows private individuals to sue perpetrators of fraud on behalf of the federal government. This is what is referred to as its qui tam provision. Individuals who become aware of fraudulent health care claims, like those in the billing department of a health care provider, can sue under the FCA and, if successful, may be able to receive up to 30% of any funds recovered. Not a bad incentive.

Examples of Health Care Fraud

As with the examples of mischaracterizing medical services and providing unnecessary treatments in the two stories above, here are other examples of fraud in the health care industry:

  • Misrepresenting dates/locations/provider of service
  • Waiving deductibles and/or co-payments
  • Falsifying a diagnosis to justify treatments
  • Billing each step of a procedure as a separate procedure (this is called "unbundling")
  • Tampering with medical records
  • Forging signatures

How Can You Prevent Health Care Fraud?

As you can see, the health care industry is besieged by costly false claims. If you're interested in helping to prevent health care fraud, here are a few tips:

  • Protect your insurance cards and benefit information
  • Don't accept unnecessary equipment, products or treatments
  • Be suspicious of medical offices that lack normal medical equipment and fail to perform normal medical procedures during visits (taking blood pressure, etc.)
  • Review your medical billing statements carefully to ensure that they are accurately reflect the treatments/equipment you received.

If you do suspect health care fraud, there a variety of reporting methods available. However, if the fraud involves claims to the federal government, you may want to consider using the qui tam provisions of the FCA as you could be awarded a percentage of the funds recovered.

Learn More About Health Care Fraud 

Health care fraud isn't a victimless crime. In fact, it's one reason why everyone's health care costs are so high. If you're in a position to uncover health care fraud, you could be rewarded for taking action to stop it. Before you do, it's important to speak with an attorney to understand your rights and options. Get in touch with a whistleblower-qui tam attorney near you today to learn more.

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