Do you want to learn more about health insurance fraud or healthcare fraud? If so, you’re in the right place. Watch the video below to get answers to your question “what is healthcare fraud?” and learn about the different types of health insurance fraud.
0:43 False Claims Act Of 1863
2:17 Qui Tam Action
4:02 Treble Damages
I was asked to talk a little bit about types of health insurance fraud. This is a serious topic and from the standpoint of health insurance fraud, what we are generally speaking of in the legal world is the filing of false claims.
With the federal insurance payers, these would be medicare, Medicaid, Tricare and in the case of the military or the federal employees, it would be the health benefit plan.
0:43 Health Insurance Fraud: False Claims Act Of 1863
There’s an old law that actually dates back to the time of Abraham Lincoln called the False Claims Act. In the case of health care, the biggest payer by far in this country is the United States government. Interestingly enough, Medicaid is also partially funded by state governments. So fraud, and it can be simply billing to the federal payers for a procedure that’s billed but not performed at all.
1:19 Health Insurance Fraud: Upcoding
Perhaps a procedure was performed but it’s upcoded where the person is requesting more money than he or she should have for the provision of a health care service, or perhaps there is a problem with a kickback, where a kickback is being paid in consideration of a referral, or where a practitioner is referring healthcare work to some entity in which he has an ownership interest such that he’s essentially double-dipping.
In the case where health care fraud is performed, the United States government clearly has a major interest in identifying that fraud and abuse and stopping it. As such, when a private patient reports such a situation to his or her legal counsel, that lawyer is required if he is seeking some redress, to deal with the United States government through what is called a Qui Tam Action.
2:17 Health Insurance Fraud: Qui Tam Action
As a result, what the government essentially does is if a plaintiff, or in the case of false claims act cases, is called a relator. If the health care fraud is reported by that relator, the government gets a shot to look at that material and to determine if there is truly merit to the relator’s claim. And if that’s the case, the government will prosecute the case, they will intervene, pursue the case, and the relator is compensated, basically up to twenty-five percent depending on the scenario of what the government is able to recover from the individuals responsible for the fraud.
So in other words, just for the sake of simple numbers, if the government recovered a hundred thousand dollars, the relator could potentially recover twenty-five thousand. Frequently, it’s twenty percent instead of twenty-five depending on whether the government intervenes or it doesn’t. But if the government does intervene, the case is usually going to be settled because these cases typically do not turn out favorably for the defendants. The government has vast resources, they’re able to investigate and identify frauds more quickly than virtually any other entity around us.
There generally is ample motivation for these defendants to look at trying to settle with the United States government. The penalties are enormous. They can be up to twelve thousand dollars per claim. So you can do the math if there are a hundred claims at twelve thousand dollars each. Usually, though, they’re more.
4:02 Types of Health Insurance Fraud: Treble Damages
To boot, they can be assessed trebled damages, so three times whatever the value of the fraud is. And remember, the relator, the whistleblower, is able to take a reasonably decent percentage of whatever the government is able to recover.
This is an area in particular where I have some pretty significant experience. It also demands an in-depth knowledge of health care, it’s delivery, and where fraud can occur in the healthcare system, and they’re a substantial number and a substantial number of variations that it can occur on that theme.
That is, these fraudsters are always looking for a bigger and better way to defraud the government and make money doing it. It’s important that if you suspect healthcare fraud, that you report it to a qualified attorney who has experience in filing Qui Tam Actions, both at the state and federal levels. There are state False Claims acts in most cases, and again, if Medicaid is involved, you can get the state and the feds involved, and in doing so, not only help your country and its treasury but also help yourself.
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