Hospitals are at the center of our modern health care industry. With their extensive networks of physicians and other care providers and purchasing power for medical devices and pharmaceuticals, their actions have a substantial impact on the care that patients ultimately receive.
With that influence, however, comes the opportunity to take advantage of the system for undue financial gain. Every year, the federal government loses billions of dollars to Medicare fraud, some of which is perpetuated directly by hospitals. One of the most effective ways of addressing and preventing fraud in the system is the use of qui tam litigation, in which an individual with evidence of fraud assists in a government prosecution. Warren | Benson Law Group has been at the forefront of qui tam litigation in the United States for more than 25 years, helping individuals throughout the country recover more than half a billion dollars in government prosecutions.
What Does Hospital Fraud Look Like?
Our firm is a national leader in successfully prosecuting whistleblower reward cases against hospitals who commit Medicare fraud. Examples of fraud involving hospitals include:
- Upcoding and unbundling for services provided to patients
- Seeking reimbursement for treatments that were never performed
- Engaging in financial arrangements such as kickbacks and illegal referral fees with device manufacturers, drugmakers and service providers
- Disproportionate Share Hospital (DSH) fraud in serving underprivileged patient populations
Real-world examples of hospital fraud include:
- In Virginia, a hospital was billing for hospital outpatient procedures using codes reserved for physician’s office visits instead of an outpatient procedure performed at the hospital. Medicare pays a higher rate for physician’s office visits to reflect the cost of their overhead. Hospitals receive a separate facilities fee to cover overhead and, as a result, the correct reimbursement rates for hospital outpatient services are at a lower rate. The hospital agreed to a settlement of $3 million.
- A Pennsylvania hospital agreed to pay a $2.7 million settlement because of its upcoding fraud. The hospital was submitting claims for a complex form of pneumonia when the correct diagnosis indicated a simpler form that is reimbursed at a lower rate. In addition, the hospital agreed to pay $562,201 for other upcodings, including false claims for septicemia, a blood infection.
- An Arizona hospital paid a $3.3 million settlement for overcharging state and federally funded health care programs for outpatient clinical laboratory services by double billing and unbundling. The hospital used two or more billing codes in lieu of the single billing code for the variety of lab tests that were performed as a single group of tests.
- A California hospital chain agreed to pay a settlement of $2.9 million because it knowingly kept overpayments made by Medicare and did not return those payments in a timely manner. The hospital knew of the overpayments but remained silent and even filed false cost reports that did not reflect the overpayments.
- A Delaware hospital submitted false claims under its cost report for nonexistent expenses related to employee costs. The hospital agreed to a $3.7 million settlement when it was caught submitting fraudulent health benefit costs for its employees that it had not actually incurred. The hospital had fraudulently claimed on its cost report an expense for health insurance for its employees, when in reality it had not incurred the expense at all.
Learn If Your Information Can Result In A Successful Qui Tam Prosecution
If you have information that you believe points to widespread hospital fraud, we invite you to learn more about the rewards and protection offered to whistleblowers, or contact our firm now for a confidential consultation with one of our nationally recognized lawyers. Call 800-844-4406 or send a secure email.