What is Medicare and Medicaid fraud? How are Medicare or Medicaid whistleblowers helpful

by Brown LLC Whistleblower Law Firm,Class Actions and Injury La

Fraud, misconduct, or illegal activities, call it as you please, in Medicare, Medicaid and pharmaceutical industries is substantial and add significantly to increasing Medicare costs. And, unfortunately, this could be all-encompassing at the time of national or global health crisis. The state and federal governments together spend billions of dollars every year on a variety of programs including Medicare and Medicaid.


Did you know that the healthcare industry is prone to committing misconduct, where whistleblowers help discipline the fraud?

Specialists approximate that up to 10 percent of all Medicare expenditure derives from false claims. This amounts to multiple billions of dollars per year in falsified billings to Medicare and many other government healthcare schemes. Whistleblowers who choose to come forward and report Medicare fraud by bringing cases under the federal False Claims Act might be eligible to be rewarded a share of the financial recovery by the government. The False Claims Acts’ whistleblower rewards acknowledge the substantial role whistleblowers play in saving billions of dollars for the U.S. taxpayers while ensuring the uprightness of government healthcare programs. 

Who commits healthcare fraud?

Healthcare fraud that can be reported by whistleblowers is carried out by certain numbers of actors all the way through the healthcare system, including hospitals, clinics/doctors, pharmaceutical manufacturers, labs, pharmacies, managed care organizations, and the like.   


These healthcare centers might bill for services that were never provided, the bill for needless procedures, admit patients who could have been treated on an outpatient basis, infringe kickbacks laws, and be engaged in much other wrongful behavior. 

Healthcare service providers

Doctors, clinics, surgical centers, and therapists might bill for services never provided or never medically essential or upcode a cheaper medical procedure for those of the highest rate, amongst other misconduct plans. Healthcare service providers are as well subject to anti-kickback statutes as well as Stark Law. 

Pharmaceutical organizations

These organizations do engage in wrongful procedures quite often through manipulation of clinical trials, off-label marketing, and other kinds of violations. Pharmacies might bill for medicines not offered, divert medicine for unlawful purposes, fake prescriptions, and even over-bill. 

Medicaid manufacturers and distributors

Medicaid-related misconducts could happen with everything from x-ray machines to bedpans. Fraudulent behavior involves kickbacks from the suppliers, charging for defective or needless equipment, off-label marketing, and many such practices. 

Skilled nursing facilities

Skilled and Nursing facilities offer care for patients in need of close attention, however, do not necessarily require a hospital stay. Misconducts or wrongful activities might involve kickback violations, billing for services never offered or medically necessary, and overbilling. 

What kind of healthcare misconduct can be reported?

People involved in the healthcare system are required to follow certain rules. When these people deliberately fail to follow the laws and regulations, they are considered cheating the system. The most common fraudulent designs and types including:

  • Violations of laws forbidding kickbacks or any sort of financial arrangements
  • Upcoding
  • Risk adjustment fraud
  • Unbundling
  • Billing for service never provided
  • Billing for service not medically necessary
  • Billing for unlicensed personnel
  • Electronic health record fraud
  • Off-label marketing of prescription drugs
  • Defective products and manufacturing violations
  • Rebate or discount and other pricing fraud
  • Clinical trial or FDA fraud
  • Compounding pharmacy fraud

You can contact Medicare whistleblower or Medicaid whistleblower attorneys at Brown, LLC for a confidential consultation on Medicare or Medicaid whistleblowing. 

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Created on Jul 12th 2021 00:59. Viewed 627 times.


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