Whistleblower

In many health fraud cases, providers bill for services not delivered to patients. For example, doctors bill for procedures not performed, therapists bill for sessions that never took place, and nursing homes bill for supplies not purchased or used. Often there is fabrication of records to support the false billings.

Examples. A man set up durable medical equipment companies and an elaborate system of sales staff to obtain Medi-Cal eligibility numbers from beneficiaries and institutions. That information was used to bill for incontinence supplies that for the most part were not provided. He pled guilty to fraud and paying kickbacks. He agreed to pay $3 million to settle civil claims for Medicaid fraud and was excluded from the Medicare and Medi-Cal programs for 30 years.

Anesthesiologist routinely billed Medicare an extra hour and a half for every open-heart surgery in which he participated. In addition, his nurse anesthetist also over billed. The anesthesiologist was excluded from participation in the Medicare and Medicaid programs for two years and paid a $500,000 settlement.

A hospital falsely billed Medicare for transporting patients and providing advanced life support services, when in fact it had provided technicians for advanced life support but another company performed the actual transport. The case was settled and not only was the hospital was not reimbursed for ambulance services; it also agreed to pay $374,430 in civil penalties and restitution. As part of the settlement agreement, the hospital agreed to set up a training program for employees to insure that Medicare is billed properly in the future.

An orthopedic surgeon billed for services performed while, at the same time he was out of the country. The surgeon billed for X-ray and physical therapy services performed by unlicensed, untrained personnel. In the settlement, he agreed to pay a total of $581,500 for submitting false claims for Medicare reimbursement, convicted of theft from the Medi-Cal program for similar false billings, and was excluded from the Medicare and state health care programs for 25 years.

A state-owned hospital was sued for over billing for services. The evidence showed the hospital was billing for ventilation management for all intensive care patients, even if they did not received this service. The hospital claimed to have understood from the carrier's medical director that it could bill for Medicare and private insurers in the same fashion. The hospital agreed to repay Medicare $521,170.