Reporting Medicaid and Medicare Billing Fraud in North & South Carolina
Whistleblowers help expose billing scams against the government – and can receive a reward!
Phantom Billing, Medical Billing Fraud, and Medical Upcoding: Healthcare Fraud Against the Government
Whistleblowers play a vital role in protecting the integrity of government healthcare programs by helping to uncover Medicaid and Medicare billing fraud that costs taxpayers billions of dollars each year. Many of these cases come to light because a former employee, medical biller, coder, or patient recognized a pattern of false claims and had the courage to report it. By coming forward with evidence of wrongdoing and false claims related to Medicare and Medicaid billing — such as phantom billing, upcoding, unbundling, and overbilling of services and prescriptions — whistleblowers help safeguard these essential programs from healthcare fraud.
Under the False Claims Act, individuals who expose fraud may, not only help stop unethical practices, but also receive financial rewards Under the False Claims Act, individuals who expose fraud may not only help stop unethical practices, but may also receive a financial reward, generally 15-25% of the government’s recovery if the government intervenes in the case, or 25-30% if it does not. Do you suspect fraud? At Carolina Whistleblower Attorneys, we’re experienced in pursuing whistleblower claims in North and South Carolina for Medicare and Medicaid waste and abuse.
Filing an FCA claim requires an attorney and follows a specific legal process. Learn more about how qui tam lawsuits work and what to expect.
Contact us today at 1-888-292-8852 for a free, confidential discussion that can give you peace of mind and help you decide how you want to proceed.
Understanding Medicare and Medicaid phantom billing fraud
Understanding Medicare and Medicaid Phantom billing fraud involves submitting claims to Medicaid or Medicare for services, procedures, or equipment that were never provided or delivered to the patient. For instance, a provider may bill for a test that was not performed or may bill for an office visit that never occurred.
What is upcoding healthcare fraud in Medicare or Medicaid?
What is Upcoding involves billing Medicare or Medicaid for a more expensive service or procedure than what was actually provided. For example, a provider might perform a simple follow-up office visit but bill it as a more complex consultation.
Unbundling scams in Medicare and Medicaid healthcare
Unbundling occurs when healthcare providers separate components of a single procedure and bill them individually to maximize reimbursement from Medicare or Medicaid, even though they should be billed as one bundled service. A common example of unbundling is when a provider bills separately for incisions and closures during surgery.
Types of Medicare and Medicaid overbilling of services
Types of Medicare and Medicaid Overbilling of Medicare and Medicaid services scams involve healthcare providers intentionally inflating charges, misrepresenting services, or billing for services that were not necessary or never provided. For example, if a clinic bills for a physical therapy session even though the patient never attended the appointment.
Overbilling of Medicare and Medicaid prescriptions is fraud
Overbilling of Medicare and Medicaid prescriptions is fraudHealthcare providers or pharmacies may inflate costs, prescribe unnecessary medications, or overstate the quantity of drugs provided to receive additional reimbursement. Other examples of this type of prescription ovebilling fraud include overbilling for brand name drugs instead of generics or billing for drugs not dispensed.
Other types of Medicare and Medicaid billing fraud to be aware of
Unfortunately, there are many other Medicaid and Medicare waste and abuse schemes in which healthcare providers, suppliers, and pharmacies try to scam the government. Other ways fraudsters inflate costs or falsify claims to receive higher-than-deserved Medicare or Medicaid reimbursements include:
- Double billing for the same service, procedure, or medication
- Misrepresenting non-covered services to make them appear reimbursable
- Falsifying patient diagnoses to justify costly procedures or treatment not medically necessary
- Billing for unnecessary tests, procedures, or services
- Billing Medicare for durable medical equipment, such as power wheelchairs or back and knee braces, that a physician never ordered or a patient never received
- Billing for home health visits that never took place, or admitting patients into hospice care who are not terminally ill in order to collect higher daily hospice reimbursement rates
- Billing for non-covered services hoping the government pays without noticing
- Billing for services provided due to illegal kickbacks or bribes
- Submitting claims for deceased patients
Gathering evidence for your Medicare or Medicaid billing fraud case
If you suspect billing fraud, the strength of your case often depends on the specific, non-public evidence you’re able to provide. Before you speak with an attorney, it can help to think through what you’ve seen or have access to, without taking any action that could put your safety or your case at risk. This may include:
- Billing records, claim forms, or billing codes tied to the suspected fraud
- Internal emails, memos, or messages discussing billing practices
- Patient charts, orders, or documentation that contradict what was billed
- Names, titles, and dates connected to the people involved
- Patterns you’ve noticed over time, such as recurring codes or repeated errors that never get corrected
You don’t need to have all of this before reaching out. An experienced whistleblower attorney can help you understand what you already have, what else may be useful, and how you can gather additional evidence safely and legally.
How Carolina Whistleblower Attorneys can help you fight Medicare and Medicaid billing fraud
If you suspect Medicare or Medicaid billing fraud and are considering exposing it, it’s important to have an experienced guide to help you through the whistleblower process. Our whistleblower team is led by former U.S. Attorney Bill Nettles. During his tenure, Bill led South Carolina to become one of the top four states in the nation for whistleblower recoveries.1,4
Our mission is to expose fraud against the government, and we stand with those who have the courage to report all types of medical billing fraud involving Medicare and Medicaid. Our client success stories prove our dedication to seeking justice.1,4
We operate on a contingency fee basis, which means we cover all the costs of building your case, and you don’t pay a penny unless we win an award for you—guaranteed.2 With our You-First Policy, we put your interests first every step of the way.
Whistleblowers can play a critical role in identifying overbilling schemes. If you suspect any type of Medicaid or Medicare fraud, let’s have a confidential conversation. We can answer your questions and help you explore your options. The consultation is free, and there’s no obligation.
Contact us online or call 1-888-292-8852 today!
FAQs
What are the most common Medicare and Medicaid billing fraud schemes?
Common schemes include phantom billing for services that were never provided, upcoding, unbundling, overbilling for services or prescriptions, durable medical equipment fraud, and billing for home health or hospice services that did not happen as described.
How much can a whistleblower receive for reporting Medicare or Medicaid billing fraud?
Under the False Claims Act, a whistleblower may generally receive 15-25% of the government’s recovery if the government intervenes in the case, or 25-30% if the case successfully resolves without government intervention. The exact potential amount depends on the facts of your case.
Can I report Medicare or Medicaid fraud anonymously and keep my identity confidential?
Whistleblower lawsuits under the False Claims Act are filed under seal, which keeps your identity confidential from the public and the defendant while the government investigates. An experienced attorney can explain your right to initial confidentiality and help you throughout the process.
Do I need an attorney to file a Medicare or Medicaid whistleblower case?
Yes. Federal law requires a qui tam lawsuit under the False Claims Act to be filed by an attorney on the whistleblower’s behalf. Working with an experienced whistleblower attorney can also improve your case’s chances of being taken up by the government.
What is the statute of limitations for filing a Medicare or Medicaid fraud case?
The False Claims Act contains two limitations periods. The first period requires that the action be brought within 6 years after the violation occurred. The second period requires that the action be brought within 3 years after the United States official charged with the responsibility to act knew or should have known the relevant facts, but not more than 10 years after the violation. Whichever period provides the later date serves as the limitations period. Because these timelines get complicated and are fact-specific, it’s best to speak with an attorney as soon as you suspect fraud.
Am I protected from retaliation if I report Medicare or Medicaid billing fraud?
Yes. The False Claims Act protects whistleblowers from retaliation, such as being fired, demoted, or harassed for reporting fraud, and may allow remedies like reinstatement and double back pay if retaliation occurs. Our You-First Policy means we work to help protect you from retaliation throughout your case.
Which government agencies investigate Medicare and Medicaid fraud?
The Department of Justice (DOJ), the US Department of Health and Human Services Office of Inspector General (HHS-OIG), and the Centers for Medicare & Medicaid Services (CMS) are among the federal agencies that investigate and pursue enforcement action against Medicare and Medicaid billing fraud.
Awards we’ve won
