Report Medicare Fraud at www.usawhistleblower.com

• $668 Million per day!
• $27.8 Million per hour
• $464,041 per minute!

Be Informed:

The Medicare and Medicaid programs provide security for you and your family.  Fraud diminishes the quality of treatment you receive because monies for programs and services are lost.  And, it affects everyone who pays taxes by wasting billions of tax dollars.

Example of some Medicare Schemes

AMBULANCE
 
1.) Billing the patients for advanced life support (ALS) when basic life support (BLS) was provided
 
2.)  Falsification of documentation to support increased dollar amounts to be billed (example: indicating patient needed oxygen to qualify for ALS)
 
3.) Charges are made for miles in excess of the actual miles traveled
 
CLINICAL LABS
 
1.) More tests are added than the physician ordered
 
2.) More tests are billed for than provided
 
3.) Billing separately for lab tests that could have been included in a 'panel of tests' resulting in higher reimbursement
 
What to look for:
 
1.) "Free" services billed to Medicare or other insurance coverage
 
2.) Dates of service that coordinate with visit for tests
 
3.) Review EOMBs/MSNs to insure services billed were provided
 
HOME HEALTH AGENCIES AND HOSPICES
 
1.) Billing for patients that do not meet the requirements of "homebound" status
 
2.)  Billing for services never or partially received by patient
 
3.) Billing housekeeping/custodial services as skilled nursing or therapy services
 
4.)  Shifting patients from one agency to another
 
5.)  Altering claims, duplicate billing or violating assignment agreement with Medicare
 
6.)  Issuing of unethical certificate of medical necessity for home care services
 
7.) Unethical/unfair marketing strategies (example: offering incentives such as free groceries or transportation)
 
8.)  Duplicate billing of services or not billing under current Hospice regulations
 
9.)  Billing for services at a site other than where the home care services was provided
 
HOSPITAL SERVICES
 
1.) Posting inappropriate date for discharge
 
2.) Misrepresentation of DRGs (diagnostic related groups) to enhance reimbursement by Medicare
 
3.) Improper billing of observation status which results in a higher payment under Part B (observation status is the setting where patient is NOT an inpatient but is supervised and has periodic assessments)
 
What to look for:
 
1.) Review EOMBs/MSNs to insure services billed were provided
 
2.) Request itemized statements for review and consideration
 
MENTAL HEALTH SERVICES
 
1.) Billing for unlicensed personnel to administer care to patients

2.)  Inappropriate or non-covered services are provided and processed for reimbursement

3.)  Submitting a bill for social gatherings as therapy sessions or group sessions as individual counseling sessions

4.) Community mental health centers that advertise a social gathering to seniors and received EOMBs indicating psychotherapy services
 
What to look for:
 
1.)  Group therapy sessions where recreational activities are provided
 
2.) Mental health providers with clients who are non-communicative
 
3.) Review EOMBs/MSNs to insure services billed were provided
 
NURSING FACILITIES

1) Billing social activities or life services as psychotherapy
 
2.) Billing for medical supplies the patient has not received
 
3.) Billing for custom fitted body jacket while being provided with wrap around corsets secured by Velcro straps
 
4.) Providing group therapies such as physical, occupational and speech, and billing 30 minutes of therapy for each patient as if provided individually (note: therapy must be medically necessary and ordered by health care provider)
 
5.)  Billing for ostomy supplies in quantities that exceed what is required and using the unused components for central supply
 
6.) "Gang visits" (such as optometrists, podiatrists, etc.) to many patients in a facility, most who do not have any prior system or medical condition documented in their chart to warrant billing and reimbursement
 
What to look for:
 
1.) Therapies provided to groups of patients (PT/OT/ST)
 
2.) Therapies provided to patients who cannot benefit from the services (example: in a coma or Alzheimer's)
 
3.) Notation that all patients have the same medical equipment
 
4.) Indication that special supplies are not individually labeled
 
5.) Easy access to patient files to persons other than medical practitioners
 
MEDICAL DOCTORS, OPTOMETRISTS, CHIROPRACTORS, PODIATRISTS, PHYSICAL THERAPISTS, ETC.
 
1.) Misrepresentation of diagnoses on billing to obtain payment (examples: toe nail clipping for routine foot care, comprehensive levels of eye care when lower level exam is performed, chiropractor billing for three visits and patient is seen twice, ophthalmologist falsifies documentation to support cataract surgery, billing acupuncture as physical therapy)
 
2.)  Not charging the 20% co-payment for Medicare services without regard for patient financial need.
 
3.) Billing for experimental medical services not approved by Medicare
 
4.) Billing for Home Health Care chart review when that documentation does not support reimbursement
 
5.)  Inappropriate procedural and/or diagnostic coding (example: screening procedure billed with diagnostic code)
 
6.)  Up-coding or upgrading of medical services/procedures that were provided to the patient for financial reimbursement without chart documentation to support coding
 
What to look for:
 
1.)  Patients alluding to never being seen by the physician/practitioner
 
2.)  Patients obtaining payments (cash or in-kind) for using a clinic and providing Medicare number
 
3.)  Compare statements with date and services received as well as comparison with EOMB/MSN
 
4.) Review EOMBs/MSNs to insure services billed were provided
 
5.) This billing could be a keying error in the billing/processing. Contact the office that processed the claim and request the error be corrected.
 
6.)  It billing could be a legitimate service by a provider the client did not see (lab, pathology, radiology, anesthesiology) but who performed a service for the patient, such as evaluating an x-ray.
 
7.) The services may have been provided by a nurse practitioner, physician assistant or physical therapist who is appropriately billing under the physician's provider number.

8.) Physical therapy provided to groups of Medicare patients versus one on one treatment by a licensed physical therapist.  (PT/OT/ST)

Whistleblowing Reporting of Suspected Medicare Fraud
 
If you have reason to believe someone is defrauding Medicare, simply click on the link below in red for a free case evaluation. Any and all information provided to Whistleblower Rewards Network will be kept strictly confidential and will be for the use of our designated attorneys, our investigating agents and the appropriate state and or federal government agencies. Whistleblower Rewards Network strictly prohibits the dissemination, distribution or copying of your information to any unauthorized outside parties.