Recently we heard from a potential whistleblower complaining about a physician who is ordering unnecessary tests simply to generate higher Medicare billings. The whistleblower’s story bears repeating since we suspect it is happening elsewhere. To protect confidentiality, we will use made up names in this post.
Dr. Jones often adds a diagnosis of chest pain to patients’ charts even though the patient has no history of pain. Since patients rarely see their charts, Dr. Jones simply tells the patient that in an abundance of caution, he wants to perform additional tests just to make sure the patient isn’t suffering from any cardiac problem.
Almost always the patient consents and Jones orders expensive cardiac testing including chest XRAYs and EKG’s. Sometimes he further doctors chart notes in order to justify nuclear stress testing.
The crime is ingenious. Patients think they are getting special care and testing because Dr. Jones is genuinely concerned about their health. Within the office, however, the staff knows that medical records are being falsified to justify needless tests. Jones cares about his bottom line and profits, not his patients.
Some people think Medicare fraud is a victimless crime but it certainly isn’t. Medicaid and Medicare are paid with tax dollars. Your tax dollars and mine. Physicians and clinic operators that order unnecessary tests are simply padding their pockets at our expense.
Worse, if the patient later has a critical care incident, an honest physician or ER nurse will rely on these false chart notes when making emergency care decisions.
Want more convincing? Our health dollars are not unlimited. There are still folks who don’t get needed medical care because there simply isn’t enough money to go around. Some folks don’t get the care they truly need while a few greedy doctors stuff their pockets.
Lest you think the problem is very isolated, the FBI calls Medicare fraud an epidemic and claims that taxpayers lose billions of dollars each year because of this type of fraud.
Medicare fraud comes in al different forms. Common schemes include kickback for referrals, unnecessary treatments or diagnostic tests, billing for services not performed, prescribing medications for non-approved off label uses and “upcoding.”
Fraudsters are always inventing new ways to commit fraud. Luckily the best line of defense is a concerned patient or healthcare worker. One of the biggest difficulties we encounter, however, is getting the would-be whistleblower to step forward. Despite a strong anti-retaliation law that pays double lost wages and legal fees, some whistleblowers feel they will be ostracized if they create waves.
As more and more whistleblowers come forward – last year was a record year according to the U.S. Department of Justice – we expect the social mores regarding whistleblowing will change. The False Claims Act also helps. That law allows whistleblowers in Medicare cases to receive a percentage of whatever the government collects from wrongdoers. Because the law carries huge penalties, awards can become sizeable.
If you have information about Medicaid or Medicare fraud, give us a call. Our whistleblower clients have been awarded over $100 million! Obviously, not all awards are the same but million dollar awards are not uncommon, particularly in Medicare fraud cases.
MahanyLaw – America’s Medicare Fraud Lawyers