Medicare and Medicaid fraud cost taxpayers around $60 billion per year. A private citizen can help by filing a lawsuit against suspected perpetrators in a U. S. District Court according to procedures set forth in the False Claims Act, and can get 15% to 30% of recovered damages. Medicare will give rewards of up to $1000 for exposing violations of healthcare laws. Health care law firms will also give rewards to individuals that provide information leading to the recovery of damages.

Examples of violations of healthcare law are nursing homes billing for supplies that were never actually purchased or used, and clinical labs and hospitals adding the cost of unnecessary blood tests to the bill.

Fraud, which also violates medical malpractice law, occurs when physicians bill for diagnostic procedures that were unnecessary or never performed. Ophthalmologists, for example, have billed for laser surgery when only post-operative suture removal was performed.

Other violations of health care laws are

1. Hospitals that give the wrong procedure codes to the large insurance companies that have a contract to pay claims using government funds.
2. Health care providers who avoid the lower reimbursement rates for blood tests commonly done together by representing that the tests were done separately.
3. Transportation companies that bill for life-support transportation when only wheelchair transportation was provided.
4. Health care providers who bill for supervised kidney dialysis of critically ill patients when only routine backup maintenance was provided.
   
5. Hospitals that submit duplicate claims for outpatient services that were performed during the hospital stay.
6. Pharmaceutical companies that pay kickbacks to doctors for prescribing certain drugs.
7. Healthcare providers of inpatient and outpatient services who pay kickbacks to physicians for referrals.
8. Healthcare providers who forge doctor’s signatures on certificates of medical necessity and falsify credentials of employees.
9. Healthcare providers who inflate expenses for reimbursement claimed in annual Medicare "cost reports."

Action Steps
The best contacts and resources to help you get it done

Check the Medicare website if you suspect violation of healthcare laws

The official website for Medicare has a section on fraud with clues that health care laws are being violated. The website also explains how the suspected fraud should be reported.

I recommend: The full list on the Medicare website should be reviewed. Suspicious actions are representations that the equipment or service is free and not charging co-payments without checking on your ability to pay. Charging co-payments on Medicare covered preventive services, such as PAP smears and prostate specific antigen (PSA) tests, is also suspicious. A guide to preventive services can be downloaded from the Medicare website.

Check the Centers for Medicare and Medicaid Services (CMS) for information on healthcare law fraud

The CMS administers Medicare and Medicaid and issues a Medicare Summary Notice (MSN) to beneficiaries. The MSN lists the health insurance claims made for the beneficiary on a quarterly basis.

I recommend: Read the instructions for reviewing MSNs on the Medicare website. CMS supplies a list of publications that can be downloaded about fraud prevention. You should compare your MSN billing statement with your own records and look for charges for something you didn’t get, billing for the same thing twice and services that were not ordered by your doctor.

Seek out health care attorneys at the Qui Tam Online Network if needed

This organization's website is supported by healthcare lawyers and environmental lawyers interested in representing plaintiffs (also called relators) in False Claims Act lawsuits.

I recommend: The Qui Tam Online Network contains a considerable amount of information about whistle-blower or qui tam lawsuits. One of the major law firms in this area is Phillips & Cohen LLP. This law firm claims to have recovered over $2 billion dollars from whistle-blower actions.

Learn about State False Claims Acts and how they relate to healthcare law

Many states have enacted false claims acts to help uncover fraud in Medicaid.

I recommend: The website of the Office of Inspector General of the U. S. Department of Health & Human Services has a review of the false claims acts by state. The False Claims Act Center Legal Center has a considerable amount of information on this topic.

Tips & Tactics

Helpful advice for making the most of this Guide

• •  Under the Medicare Secondary Payer Act, Medicare may not make a payment when the cost is covered by a workers' compensation law or liability insurance plan. Citizens have sued health care providers around the country for violating this law, arguing that they had standing to sue and to get a percent of recovered monies. Such lawsuits have been dismissed because this act, unlike the False Claims Act, does not allow for qui tam (whistle-blower) lawsuits.
• •  A person considering filing a whistle-blower lawsuit should consider doing it pro se or with a general lawyer rather than a medical malpractice attorney or healthcare lawyer. False Claims Act cases are filed in camera, without even the defendants knowing, to allow the government to investigate the case. If the government declines to participate, the relator can proceed with the lawsuit and get a percentage of any recovered money. If the government decides to participate in the action, the chances of success will be greater. A quick filing of the action can be important. If the same complaint has already been filed against the defendant, the second complaint will be dismissed.