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False Claims Act and Health Care Fraud

Due to the immense number of health care claims submitted in the U.S.  and the privileged access that certain persons have within the health care community, the Government utilizes whistleblowers, acting under federal and state false claims acts. to detect and pursue health care fraud.   Whistleblowers are often in the best position to detect fraudulent conduct and to bring it to light by filing a qui tam lawsuit on behalf of the government.  If you believe you have knowledge of fraudulent conduct on the part of a health care provider, contact The Callan Law Firm, P.C. to discuss your options.  To learn more about the most common types of health care fraud, read on below.


There are a number of ways health care providers can defraud federal and state government health care programs, including, but not necessarily limited to:

  • Services Never Rendered: The submission of a claim for health care services, treatments, diagnostic tests, medical devices or pharmaceuticals that were never actually provided.
  • Kickbacks: The federal Anti-Kickback Statute prohibits any offer, payment, solicitation or receipt of money, property or remuneration to induce or reward the referral of patients or healthcare services payable by a government health care program, including Medicare or Medicaid.
  • Up-Coding: Billing of insurance programs is processed by filing claims which use a system of numerical codes with pre-established definitions.  Examples of such codes include CPT, E&M, HCPCS, ICD-9.  Up-coding is defined as occurring when a provider files a claim for health care services or equipment for a more expensive (or more involved) procedure or test, than what was actually performed.  Basically, billing for more than what the provider actually did or provided to the patient.   Up-coding can be a violation of the Federal False Claims Act.
  • Bundling and Unbundling: Health care programs often have special reimbursement rates for groups of procedures that are performed together, such as laboratory tests or certain E&M codes which must incorporate particular procedures. One type of fraud is to “unbundle” such grouped procedures and bill each one individually.
  • Lack of Medical Necessity: Generally, in order to be reimbursable, health care services, treatments, diagnostic tests, medical devices and pharmaceuticals must be medically necessary (or “indicated”). By law, providers are obliged to document the basis (medical necessity) of the treatment or services for which they are seeking reimbursement.  Where services are not medically necessary or not properly documented, submitting claims for such services is often fraudulent.

Despite numerous whistleblowers and federal government efforts to prevent health care insurance fraud, fraud continues to permeate the system.  This widespread fraud is a substantial cause of the rise in health care costs.   Whistleblowers help regulate the healthcare industry by deterring and punishing fraud and can significant funds if their report leads to a positive recovery of fraudulently gained funds.  If you have knowledge of potential fraud and would like to discuss your options with an attorney, contact us by clicking here.