Health care fraud that can be reported under the whistleblower provisions of the False Claims Act can involve many types of wrongdoing. Whistleblowers may have witnessed various kinds of health care fraud that collectively result in billions of dollars of false claims paid by the government each year.
Types of health care fraud include:
- Overbilling or incorrect billing for services. This can include up-coding, unbundling, or other duplicative billing schemes.
- Off-label promotion and marketing of drugs and medical devices.
- Billing for services not provided or services that were not medically necessary, including prescribing unnecessary medications.
- Fraudulent risk-adjustment data supplied to health care.
- Acceptance or offering of kickbacks or bribes of any kind, including illegal referrals, in violation of the Anti-Kickback Statute and Stark Law.
- False pricing and cost reports, including false certifications.
- Falsifying claims or diagnoses.
- Reimbursement when a beneficiary is not eligible for reimbursement.
- Billing for “ghost patients,” or claims made for a patient that either does not exist or who never received the service or item billed for.
- Retention of overpayments.
- Hospital and other medical provider fraud. Hospitals, hospice centers, outpatient facilities and other health care providers are required to submit cost reports and other documents in order to be eligible for receipt of Medicare/Medicaid funds. Falsification of those documents and false statements in support of these submitted materials often provide the basis for False Claim Act liability.