How to Identify and Report Health Care Fraud

The Medicaid program provides health benefits to households with low incomes that either do not have medical insurance or lack insurance. The federal government sets the general Medicaid guidelines, but each state sets out and monitors the program requirements.

Manufacturers of organized crime and a tiny minority of dishonest providers are responsible for most of the fraud in health care, “according to Health care fraud.” The most common types of healthcare fraud include the fraud of services that have never been performed either by means of factual data, sometimes obtained via identity robbery, to produce complete claims or by adding charges for non-existent procedures or services.

This involves billing for services or procedures that are more expensive than they provided or performed, commonly referred to as “upcoding,” i.e., for a higher-price treatment than provided (often which requires the patient’s diagnosis code to be “inflated” in a more severe condition consistent with the false procedures code).

Unnecessary medical services are only performed to generate insurance payments. The abuse, which was seen mainly in cosmetic operations schemes in which non-concerned cosmetics processes, such as nose jobs, are incurred by patient insurers as deviant septum repairs, is a covered treatment to obtain insurer insurance.

Falsifying a diagnosis of a patient to justify medically unnecessary tests, surgeries, or other procedures. Apply each step as if it was a separate procedure. Billing a patient for services pre-paid or fully paid for under a benefit plan under the terms of a managed care contract exceeds the co-payment amount. Patient referrals accept kickbacks.

Waive a co-paid patient or dental care deductible and over-fill an insurance carrier or benefit plan. Assurers often make the waiver policy for co-payment through the contracting process of the insurer. At the same time, Medicare regularly prohibits waiving co-paid pay and may not be waived due to “financial difficulties.”

The Medicare Fraud

Medicare fraud is costing US contributions in abuse, fraud, and waste approximately $60 billion a year. This is money that comes straight out of the pockets of taxpayers’ hard-earned checks to unethical and dishonest care providers. Also, patients who depend on medical services are swindled off the services they need, since gay, unscrupulous parties are distracted from resources to pay the costs of others.

You may well have seen Medicare fraud practices close up, carried out by co-workers, administrators, and superiors if you are a doctor, nurse, pharmacist, or employee of a medical provider or insurance company. There are ways to report Medicare fraud to prevent injustice for those who are courageous and loyal with their people, and you can even report Medicare fraud in anonymity. Furthermore, in return for reporting Medicare fraud money rewards may be available.

Reporting A Fraud

The Inspector General’s Office can report fraud directly through a 1-800-HHHS‐TIPS call to the Inspector General’s Office and contact the Inspector General’s Office online.

Your call or request will remain confidential to the Inspector General’s Office. You can also report anonymously to the office. You can be eligible for a reward of up to $1000 by reporting Medicare fraud to the Office of the Inspector General.

A second and lucrative option is the claim of a False Claims Act (FCA) against the offending individuals and associations which have to commit the fraud, which is to obtain rewards through reporting of medicare fraud. In a complaint by the FCA, a whistleblower files a suit against the offending parties through his or her counsel, and the federal government can then take up your demand. If you can provide the government with data that leads to a successful FCA claim, you can claim up to 30% of the government’s total recovery as a whistleblower. Given the massive amounts of Medicare fraud, even the millions could be considerable.

Medicare fraud, usually perpetrated by medical practitioners, suppliers of equipment, and related bodies who claim Medicare money for services that they have not provided, is a vast, multi-billion dollar industry. Several such cases are investigated and prosecuted in the Office of Inspector General of Medicare, some of them brought to light by Medicare beneficiaries who notice and report on something incorrect. It is often the result of the study of your Medicare Summary Notice to show that Medicare paid for the service or item they did not receive.

With Health Care Fraud, they believe that the fight against fraud, waste, and abuse in health care is measured both through convictions as well as through effective disincentives.

James Bell

Bell is in admission with the Bar in the States of Texas, California, and New York, and obtained his undergraduate and law degrees from Southern Methodist University. He continues to serve in a wide breadth of cases, including but not limited to healthcare disputes; Qui Tam litigation; white-collar criminal defense; catastrophic injury; ERISA; business fraud; bankruptcy; professional negligence/malpractice; oil & gas; complex securities disputes; divorce; child custody; and real estate fraud cases.


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