Managed care insurance fraud is an unfortunate reality that affects taxpayers, the government, and the millions of individuals enrolled in government-funded health plans. It’s a costly crime that steals at least $308.6 billion from American consumers every year. We must all work together to put a stop to schemes like upcoding and phantom billing by …
Author Archives: fishbat
The Impact of Risk Adjustment Fraud in Managed Care Insurance
Managed care is a form of health insurance that aims to reduce costs and improve quality of care by leveraging contracts with care providers and medical facilities to increase efficiency of coordinated patient care. Within the system, federal and state governments contract private insurers, also known as Managed Care Organizations (MCO), to provide health insurance …
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Becoming a Whistleblower: What to Expect When Reporting Managed Care Insurance Fraud
Fraud in managed care is an unfortunate reality that costs the government and taxpayers billions of dollars each year. Schemes like falsifying patient records, upcoding, cherrypicking, and enrollment fraud siphon money away from the 160 million Americans enrolled in legitimate government healthcare programs, increase taxes, and contribute to rising healthcare costs. This is why it’s …
Managed Care: 3 Successful Fraud Cases and Awards
Unfortunately, Medicare, Medicaid, and other government healthcare programs are impacted by fraud. However, we’ve seen a number of successful managed care fraud cases resulting in settlements and whistleblower rewards over the last few years. In managed care, federal and state governments contract private insurers, also known as Managed Care Organizations (MCO), to provide health insurance …
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Managed Care Fraud: Schemes That Can Lead to FCA Liability
Managed care fraud is an unfortunate reality that costs the government and taxpayers billions of dollars each year. Managed Care Organizations (MCO) involved in managed care fraud game the system by falsifying patient records and miscoding patient diagnoses in order to qualify for additional funds. This type of fraud takes money away from legitimate government …
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Rise of Telehealth Fraud in the Healthcare Industry
In July 2022, the Department of Justice (DOJ) announced criminal charges against 36 defendants for committing a variety of alleged schemes to defraud Medicare using telehealth. According to the DOJ, the alleged actions of the defendants led to $1.2 billion in medical fraud, with much of that coming from fraudulent telehealth claims for cardiovascular and …
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Top Three Healthcare Fraud and False Claims Recoveries of 2021
Fraud in the healthcare sector continues to be a major concern in the United States. According to the Health Care Fraud and Abuse Control Program Annual Report, healthcare fraud was by far the leading source of the False Claims Act settlements and judgments in 2021. In fact, more than $5 billion of the $5.6 billion …
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Pharmaceutical Fraud: Reporting Illegal Kickbacks
Pharmaceutical fraud exists in many ways. However, one of the most common tactics used in the industry is illegal kickbacks. Kickbacks are anything of value either directly or indirectly offered to a patient or physician that influences their medical decision to use a certain company or product. This action constitutes fraud because it undermines the …
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Blowing the Whistle on Healthcare Fraud: What You Need to Know
Healthcare fraud is a costly crime that affects both individuals and businesses alike. Unfortunately, scams like upcoding, double billing, and kickbacks are significant in the industry, costing the nation billions of dollars each year. It can increase taxes, expose people to unnecessary medical procedures and raise insurance premiums. The best way to fight fraud is …
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Three FCPA Enforcement Trends We Saw in 2021
The Foreign Corrupt Practice Act, or FCPA, prohibits bribery of foreign officials and physicians to enhance business deals and ensures books and records are properly maintained for full transparency of expenses. The FCPA has an extensive reach that applies to prohibited conduct anywhere in the world. Following a record-setting 2020, the year 2021 saw a …
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