Health Care Providers
Most doctors work ethically, provide high quality medical care to their patients, and submit proper claims for payment. But a small minority exploits the system. The False Claims Act makes it illegal for physicians to knowingly engage in any of the following practices in connection with federally-funded health programs (such as Medicare, Medicaid, and TRICARE):
- Billing for fictitious services or patients
- Billing for medically unnecessary services
- Billing for services performed by an improperly supervised or unqualified employee
- Billing separately for tests or procedures that should be billed together in order to maximize reimbursement (“unbundling”)
- Routinely waiving patient copayments
- “Self-referring” patients to surgicenters, imaging centers or other facilities with which the physician, or an immediate family member, has a financial relationship
- Offering, paying or receiving remuneration in exchange for, or to influence, the referral of patients (“kickbacks”)
- Receiving goods or services from drug companies for free or at below fair market value
- Selling patients drug samples the physician received for free
- Using billing codes that reflect a more severe condition than actually existed or more expensive care than was actually provided (“upcoding”)
- Billing for medical devices or implants the physician’s own distributorship provides (“PODS”)
- Improperly certifying patients for home health services or durable medical equipment
A number of successful False Claims Act cases have been brought against physicians. By way of example:
In 2014, an ophthalmologist, agreed to pay $1.4 million to settle claims that he violated the False Claims Act by falsely billing government health programs for laser eye procedures that were not medically necessary or reasonable. Read more
In 2013, a dermatologist, agreed to pay $26.1 million to settle claims that he violated the False Claims Act by accepting illegal kickbacks from a pathology laboratory, in return for sending biopsy specimens to the lab, and also performed thousands of unnecessary skin surgeries known as adjacent tissue transfers on Medicare patients. The whistleblower in this case was a pathologist who had worked at the lab. Read more
In 2011, an anesthesiologist and pain management physician, agreed to pay $1.25 million to resolve claims that he violated the False Claims Act by submitted inflated claims to TRICARE and the Federal Employee Health Benefits Program (FEHBP). Read more
In 2010, a physician, his wife, and their LLC agreed to pay $22.6 million to settle claims that he violated the False Claims Act by fraudulently overstating the severity of Medicare patients’ diagnoses (upcoding) in order to obtain higher Medicare reimbursements. Read more
In 2009, an internist agreed to pay $1.7 million to settle claims that he violated the False Claims Act by billing Medicare for higher levels of service than he actually rendered to patients and also for services never provided. Read more
In 2008, an anesthesiologist, agreed to pay $5 million in partial resolution of claims that he violated the False Claims Act by submitting claims to Medicare and Medicaid for services he never performed.
If you have knowledge and solid evidence of fraud or false claims by a physician or another health care provider, please contact our whistleblower attorneys.
Consultations are free and confidential.