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This can be seen in upcoding of services as well as billing for services not rendered. Some providers are so bold to think they can submit completely fictitious billing and not get caught. The owners of one respiratory therapy business actually went through their patient records and created fictitious claims using the insurance information of former patients, which they submitted to Medicare after the company had stopped operating.: https://archives.
A Biller for a neurosurgeon practice uncovered overpayments to the neurosurgeon practice made by the federal government through Medicare on behalf of patients. The Biller was told by the practice manager not to report the overpayments to the federal government. The Biller, believing it was fraud, reported it to the federal government. She was terminated after contacting Medicare. After being fired, she brought a Qui Tam action against the neurosurgery practice and a retaliation claim pursuant to the False Claims Act, which resulted in a confidential settlement for the employee.
A doctor working for a hospital system discovered the hospital would commonly bill for doctor services even if a medical assistant only saw the patient. The federal government reimbursed the hospital for these services through Medicare and Medicaid. Despite complaints to the hospital administration by the doctor, the billing practice continued. The doctor was terminated after reporting the suspected fraudulent billing practices to the CEO of the hospital and brought a Qui Tam action against the hospital for fraudulently billing Medicare and Medicaid. She also brought a retaliation claim under the False Claims Act for being terminated. The lawsuit resulted in a significant confidential settlement for the doctor.
A rehabilitation doctor working for a hospital uncovered that the hospital was billing for medically unnecessary services to Medicare and Medicaid. The fraud included the federal government being billed for inpatient rehabilitation services, which were not medically necessary. After being investigated and a complaint being submitted to the US Attorney’s office, the case settled for a large confidential amount for the doctor.
A Nurse Practitioner at a large hospital system uncovered that Medicare and Medicaid was billed fraudulently for her services and physician services, when neither she nor the physician saw the patient. The federal government had reimbursed the hospital for hundreds of hours of services, which had never been performed. The federal government was also billed for procedures for patients, which had never been performed. The Nurse Practitioner brought a claim under the False Claims Act because of the hospital billing for services and procedures it had never performed and being reimbursed from the federal government for those fraudulent bills.