Fraud under the False Claims Act means that a contractor has knowingly presented a false claim for payment to the United States. The fraud can occur wherever federal or state monies are directly or indirectly used to purchase services or goods.
Fraud most often occurs in areas where the United States is spending the most money. In the late 1980s, many cases were brought for fraud in connection with the defense industry.
Since the early 1990s, more Qui Tam cases have been filed as a result of fraud against government medical health insurance programs – Medicare, Medicaid and Tri-Care (Military—formerly CHAMPUS).
Currently the False Claims Act is being used more and more for fraud which results from violations of labor or environmental statutes.
Types of Medical Fraud
"Phantom Billing" - Billing for tests not performed.
Performing inappropriate or unnecessary procedures.
Charging for equipment/supplies never ordered.
Billing Medicare/Medicaid for new equipment but providing the patient used equipment.
Billing Medicare/Medicaid for expensive equipment but providing the patient cheap equipment.
A drug or equipment supplier completing a Certificate of Medical Necessity (CMN) instead of the physician.
"Reflex testing" - Automatically running a test whenever the results of some other test fall within a certain range, even though the reflex test was not requested by a physician.
"Defective Testing" - When a test or part of a test was not performed because of technical trouble (ie: insufficient or destroyed sample, machine malfunction) but is billed for anyway.
"Code Jamming" - Laboratories inserting or "jamming" fake diagnosis codes to get Medicare/Medicaid coverage.
Offering free services or supplies in exchange for your Medicare or Medicaid number.
"Unbundling" - Using two or more Current Procedural Terminology ("CPT") billing codes instead of one inclusive code for a defined panel where rules and regulations require "bundling" of such claims. Submitting multiple bills, in order to obtain a higher reimbursement for tests and services that were performed within a specified time period and which should have been submitted as a single bill.
"Double Billing" — charging more than once for the same service, for example by billing using an individual code and again as part of an automated or bundled set of tests.
"Up Coding" - Inflating bills by using diagnosis billing codes that indicate the patient experienced medical complications and/or needed more expensive treatments. (eg., billing for complex services when only simple services were performed, billing for brand-named drugs when generic drugs were provided, listing treatment as having been for a more complicated diagnosis than was actually the case.)
"Phantom Employees" - Expensing employees or hours worked that do not exist.
"Improper Cost Reports" — Submitting false cost reports seeking higher Medicare reimbursements than permitted by actual facts.
Providing substandard nursing home care and seeking Medicare reimbursement.
Routinely waiving patient co-payments.