Healthcare Fraud
By: Melissa Neiman, M.D., J.D. | Posted: 20th August 2007
Healthcare Fraud
Healthcare fraud may encompass many types of practices such as illegal kickbacks (receiving reimbursement for referrals), billing for services not rendered, billing for unnecessary equipment, and billing for services performed by a lesser qualified person. The health care providers who commit these fraud schemes include hospitals, home health care providers, ambulance services, doctors, chiropractors, laboratories, pharmacies, hospices and nursing homes. A private citizen can file a lawsuit in the name of the United States Government against companies that defraud Medicare and other federal healthcare programs. Medicare is a health program for the elderly financed through a federally-administered trust fund.
Violators may be prosecuted under the False Claims Act (“FCA”). This federal statute was originally passed by Congress in 1863 at the urging of President Abraham Lincoln. He was concerned about the numerous fraudulent suppliers who sold the Union Army faulty war supplies during the Civil War, including broken rifles, rancid food, and useless ammunition. The 1863 FCA provided both criminal and civil penalties for those defrauding the government and therefore was a way to combat the rampant fraud against the government. The FCA also contained a qui tam provision that permitted an individual initiating the suit, the whistleblower, to collect a percentage of the damages. The term qui tam refers to a lengthier Latin phrase which translates into English as "one who sues on behalf of the King, as well as for himself." Many states have passed laws similar to the federal FCA allowing the state to recover damages for fraud against the state Medicaid program. Medicaid is another health program for low-income individuals administered separately by each state.
The whistleblower can only bring a claim in a case in which the government is unaware of the fraud and the information precipitating the action. It is also important for the whistleblower to be the initial source of information regarding the fraud in order to be entitled to a percentage of the damages.
Fraudulent billing and billing for medically unnecessary services is prevalent throughout the United States. Healthcare fraud is expected to increase as people live longer. This increase will produce a greater demand for Medicare benefits. As a result, the utilization of long and short-term care facilities such as skilled nursing, assisted living, and hospice services most likely will expand substantially in the future.
About the Author
Occupation: Attorney; Medical-Legal Consultant
I am a Board certified neurosurgeon and licensed attorney authorized to practice medicine and law in Texas. During my fourteen year private practice of neurosurgery I was involved in medical malpractice litigation as a consultant, case reviewer, and expert witness. As a result of that experience I decided to become an attorney. Since completing law school I have been practicing law and using my medical background in numerous areas including, inter alia, medical malpractice and healthcare fraud. My combined medical and legal experience places me in a unique position to offer a wide range of medical-legal consultation to a variety of clients.
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Tags: health care providers, abraham lincoln, income individuals, qualified person, home health care, private citizen, ambulance services