Hospital Fraud Whistleblowing

We like to think that hospitals are places where benevolent people work to make the sick feel better – and in many cases that is the case. Unfortunately, as with any other establishment, the individuals who run a hospital can get caught up in wrongful acts just the same as any other corporation or small business. If you have reason to believe that a hospital is engaging in any of the various types of fraud we will delve into below, contact a white-collar crime attorney from Altman & Altman LLP right away.

With utilization of the False Claims Act or other whistleblower protections, like those offered specifically under the Internal Revenue Service or the Securities Exchange Commission, individuals who provide evidence leading to the government recovering a sizable monetary penalty from a hospital for fraudulent activity are entitled to up to 30 percent of that penalty that is levied.

However, proving a whistleblowing case against a hospital is a tricky matter and the False Claims Act has specific provisions requiring that accusations be well vetted and have evidence of the activity well established and proven. No whistleblower should go about an accusation without legal counsel, and in some cases whistleblowers can file a whistleblowing claim completely anonymous, which can lessen the fear of retaliation or other retaliatory courses of action taken by the guilty party.

Unfortunately, the United States healthcare system is one in which fraud can occur fervently and frequently. The Medicare system relies heavily on the honest reporting of medical billing by doctors and hospitals, so abuse and fraudulent activity occurs to such a regular extent that – shockingly – as much as 10 percent of the total Medicare budget in 2015 (some $60 billion) was estimated to be lost to fraud, waste, abuse and improper billing, and perhaps even much more than that.

This can occur in a number of ways, including a few examples as outlined below:

Fraudulent billing – Which is the knowing, fraudulent billing of Medicare or private insurance companies for services that were never provided to a patient so the hospital can receive federal government reimbursement for “providing” that service.

Fraudulent, or unnecessary procedures – The likelihood of getting caught billing for services never rendered is higher than being caught providing services that weren’t needed, so some doctors or hospitals may put patients through completely unnecessary medical procedures in order to earn back more money from that patient than they would otherwise. This could also lead a hospital to admit a patient for in-patient care rather than simply treating them on an outpatient basis, enabling them to milk the patient for more insurance or Medicare reimbursements as they stay and accrue a higher bill.

Upcoding – Refers to when a doctor or hospital performs one medical service on a patient, but bills Medicare or their insurance company for a more lucrative procedure. This enables hospitals to receive significantly more in payments for procedures that cost far less to perform.

It is obvious that such activities as outlined above are morally wrong, but they also lead to huge financial implications for the rest of the country. When entities like Medicare or private insurance companies are defrauded into paying more money, it results in higher premiums and costs for everyone else to make up for that lost money. It also erodes trust in an essential part of our public and private health sector.

It is important that such fraudulent activities be reported, and the perpetrators be held accountable for their misdeeds, and the attorneys at Altman & Altman LLP can help ensure that you are compensated for blowing the whistle on such bad deeds, should you be the one to provide the crucial information to bring about a financial penalty against the perpetrator. We can help retain your anonymity in certain cases, and will ensure you have the best chance to collect a reward for your actions.

Contact us online or call for a free consultation to go over the details of your case today at 617-492-3000 or toll-free at 800-481-6199. We are available 24/7.