One of the most common types of healthcare fraud happens when providers bill federal government programs for medically unnecessary services. While this may seem like a harmless crime, healthcare fraud drives up the cost of health care for everyone, making it harder for people to get the treatment they need. The Justice Department reported that it recovered more than $2 billion under the federal False Claims Act in just one recent year.
The Wilhite Law Firm has extensive experience with healthcare fraud whistleblower cases, including those that involve billing for medically unnecessary services in Denver. If you know someone who has defrauded the federal government, we can help you file a whistleblower lawsuit to expose the fraudulent parties. You may also be able to recover a portion of whatever money the government recovers if your claim is successful.
To learn more, contact our office today for a free and confidential consultation.
What Are Medically Unnecessary Services?
Under federal programs like Medicare and Medicaid, healthcare providers can bill the government only for procedures and services that are “medically necessary.” The agencies overseeing these programs argue that if a procedure or service isn’t going to help the patient or may actively harm them, the government shouldn’t have to pay for it.
That does not stop providers from billing these programs for unnecessary services. While some procedures or services may be in a gray area in terms of their necessity, the Centers for Medicare and Medicaid Services (CMS) has issued guidelines for what is considered medically unnecessary.
Some examples of medically unnecessary services include:
- Hospital services that could have been provided in a different, cheaper location, such as a patient’s residence or a nursing home
- Management and evaluation services that exceed guidelines for what’s considered medically reasonable and necessary
- Excessive diagnostic procedures or tests
- Tests, examinations, procedures, and procedures that are unrelated to the patient’s illness and for which the patient has no symptoms (with certain exceptions)
- Any “unnecessary services” based on a patient’s diagnosis
- Any items or services administered to a patient to assist or cause the patient’s death (assisted suicide)
CMS says a handful of services may be reimbursable, depending on a patient’s particular needs. These services include:
- Certain preventive services
- Transitional care management services
- Chronic care management services
- Advance care planning services
In addition to these guidelines, CMS requires every provider that bills Medicare or Medicaid to provide a specific symptom, sign, or patient complaint related to each service they perform that makes the service necessary and reasonable. However, healthcare providers still find ways to bill Medicare and Medicaid for fraudulent or unnecessary services.
What Are Types of Billing Fraud for Unnecessary Medical Services or Procedures?
Healthcare providers have found many billing methods for unnecessary medical services that constitute healthcare fraud in Denver. Some common examples include:
- Hospitals classifying patients as inpatients, allowing them to bill for higher reimbursement rates when the services that patient needs could be provided in an outpatient setting.
- Medical equipment companies bill Medicare for motorized wheelchairs or other items that patients do not need.
- Billing for ambulance services when the patient doesn’t need an ambulance because they’re mobile and not in immediate distress.
- Doctors billing for surgeries performed on patients who do not meet the criteria for the surgery to be considered necessary.
- Providers billing for complex, expensive tests or other diagnostic procedures that are not necessary or reasonable.
- Providers or pharmacies giving patients custom compounded drugs and billing for them when another, cheaper version of the drug is available and would serve the same purpose.
- Providers prescribing medications that are unnecessary and may be resold or diverted to unlawful users. Opioids are a common example of this.
- Providers billing for unnecessary services because they are receiving kickbacks from drug companies, equipment companies, etc.
Those are some of the most common ways fraudulent providers bill Medicaid and Medicare for unnecessary services, but they aren’t the only ones. Contact our lawyers right away if you suspect or know of healthcare fraud involving billing for unnecessary services.
How Could a Whistleblower in Denver Benefit from Revealing Medically Unnecessary Services Fraud?
The federal government has specific incentives to encourage whistleblowers to report fraud. Under the False Claims Act, individuals aware of fraud against the government can file a lawsuit on behalf of the government against the fraudulent parties. These lawsuits are known as qui tam cases. The False Claims Act states that people who report fraud and file a qui tam suit may be able to receive a portion of whatever money the government requires.
If you’re aware of healthcare fraud committed by your employer, a coworker, or another party, a qui tam lawsuit is a way to hold them accountable. At the same time, you could benefit financially as well. However, qui tam cases related to healthcare fraud can be complicated, so you’ll want to contact an attorney before taking action.
Visit Our Medical Billing Fraud Law Offices in Denver, CO
Our Qui Tam Lawyers in Denver Are Experienced in Handling Medically Unnecessary Services Cases
Qui tam cases involving fraud for unnecessary medical services can be challenging to handle, especially if you’re facing off against a provider with financial and legal resources you don’t have. But by hiring an attorney with experience handling these kinds of cases, you’ll likely have a better chance of bringing the fraudulent parties to justice, as well as recovering money for yourself.
The qui tam lawyers at the Wilhite Law Firm have many years of experience helping whistleblowers report fraud. We are ready to assist you through the process of filing a qui tam suit, and we’ll be there to guide you at every step along the way.
If you are aware of healthcare fraud and wish to do something about it, contact our office today for a free and completely confidential consultation.
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