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2 min read

False Claims Act Violations in Medicare Claims

The United States Justice Department recently disclosed that the large health insurance company Humana Inc. is under investigation for potentially defrauding Medicare. The Justice Department is currently examining the U.S. False Claims Act (FCA) violation of three companies alleged with committing Medicare fraud including Aetna Inc., Health Net Inc., and Bravo Health Inc. which is a division of Cigna Corp. A Humana spokesperson said in an emailed statement that the company has publicly disclosed it was part of an investigation by the United States Justice Department. Statistics suggest that the FCA has been the most successful weapon in combatting fraud against taxpayers with more than $40 billion recovered by the United States government since 1986 due to false claim lawsuits.


The Role of the False Claims Act

The False Claims Act prohibits any individual or business from submitting or causing another person to submit to the government a fraudulent claim for payment. These allegations can apply to a variety of types of goods, services, and government contract. In the case of Humana and these other cases, the alleged payment that violated the FCA concerns payment received through Medicare.

Types of Ways that Companies Defraud Medicare

There are a variety of ways in which corporations have attempted to defraud federal health care programs like Medicare. Some of the most common types of fraudulent conduct include the following:

  • Ghost Patients. Companies sometimes perform this kind of activity by reporting the patient who did not receive service alleged were treated or in some cases healthcare companies even create fictional patients.

  • Kickbacks. Federal law prohibits any receipt of property that is designed to reward the referral of patient or healthcare services payable by a government program like Medicare.

  • Medicare D Fraud. Medicare D involves a new outpatient prescription drug program known as “Part D” of Medicare. Private entities receive payments from Medicare for the prescription drug benefit services that are provided to Medicare beneficiaries. Medicare D is suspected to be particularly susceptible to a variety of fraudulent activity including duplicate billing, enrollment fraud, improper rebates, and overcharging.

  • Submissions for Services Never Rendered. This process involves submitting claims for medical treatment that was never actually rendered.

  • Up-Coding Services. Billing is performed by the government and private companies like Humana in a particularly complex number. The government assigns a specific dollar amount to each type of procedure. Up-coding occurs when a health care provider submits a claim for medical treatment that represents more expensive treatment than was actually provided to a patient.

The Assistance of an FCA Skilled Legal Representation

The FCA has been so effective in combating fraud because the Act encourages ordinary citizens to file lawsuits in the name of all taxpayers. At Whitcomb, Selinsky, Law, PC, our practice helps those who are faced with a variety of obstacles including the claims act. To obtain the assistance of skilled legal representation today, contact our law office by submitting our online form or calling us at (866) 476-4558.