Whistleblower

Billing Medicare/Medicaid for medical services involves a complex system of numerical codes for various diagnoses and procedures. Reimbursements are based on those codes. The coded, computerized bills submitted by providers are processed by large insurance companies ("intermediaries") that contract with the government to pay claims using government funds.

Different codes or combinations produce dramatically different reimbursements. Thus in government programs, there is a financial incentive to "upcode" or bill for a more expensive diagnosis or procedure. For example, Medicare may pay for an Xray if there is an indication of some disease but not as part of a routine check-up. Hospitals or radiology labs that wish to increase their reimbursement rates may routinely upcode all of their x-ray bills for Medicare patients by using a code indicating a disease even if there is no medical basis. . Government programs often have special for a group of procedures commonly done together, such as typical blood test panels by clinical laboratories. Some health care providers seeking to increase profits will "unbundle" the tests and bill separately for each: component, which totals more.

Examples

A company submitted billings for $3.5 million for supervised kidney dialysis of critically ill patients when only routine backup maintenance was provided for hospitalized beneficiaries. The settlement was for them to pay $1.75 million immediately and another $500,000 within five years, and to provide at no cost $1.25 million in medical care to Medicare patients over a five-year period.

A transportation company billed for basic life support transportation when it actually performed special wheelchair transportation. The company and its owners were convicted of theft and ordered to make restitution of $768,000.

An ophthalmologist billed Medicare for laser surgery when all he performed was post-operative suture removal. He and his surgery center agreed to pay $750,000 in settlement of false Medicare billings.

A laboratory submitted 300 claims for blood tests performed on hospital patients as being done by doctors working for the lab. Instead, the tests and analysis were performed by hospital technicians, and were already included in reimbursements to the hospital. The lab agreed to pay $1 million to settle the Medicare fraud charges.

Eighty-seven (87) hospitals were sued under the False Claims Act claiming that they submitted duplicate claims for outpatient services for Medicare patients performed within 3 days of admission to the hospital. These services had already been reimbursed as part of the hospital stays. Settlement $3.5 Million.

A Medicare provider of ophthalmology services was sued for fraudulent Medicare billings by its billing company. The billing service fragmented and submitted as separate claims surgical procedures which Medicare had already reimbursed the provider for as part of global payments. The service was convicted in 1989 for Medicare fraud. CMP settlements of $3.1 million and $630,000 have been made with providers in Massachusetts and Texas, respectively. Florida signed a $2.85 million civil monetary penalty with the provider. Total Settlement $6.15 Million.