Fraudulent Billing
Most healthcare fraud involves at least one form of fraudulent billing. At Barrett Johnston, PLLC, we help whistleblowers identify recognize these schemes and craft them into viable allegations because they often serve as the foundation for False Claims Act cases.
For FCA purposes, fraudulent billing refers to the submission of claims to Medicare, Medicaid, or other government programs that are false or misleading. Common schemes include:
- Upcoding: Billing for a more expensive service than was actually provided.
- Phantom billing: Charging for services never performed.
- Unbundling: Billing separately for procedures that should be billed together at a lower cost.
- Unnecessary services: Providing a service the patient does not need simply to bill for it.
- Double billing: Submitting multiple claims for the same service.
These schemes not only drain billions of dollars from taxpayers but also put patients at risk. For example, unnecessary tests or treatments may be ordered simply to generate revenue, exposing patients to harm.
Fraudulent billing can be perpetrated by hospitals, clinics, doctors, laboratories, or even pharmaceutical companies. Whistleblowers — often billing specialists, nurses, or administrators — are usually the first to spot irregular patterns.
Under the False Claims Act, fraudulent billing can trigger treble damages (triple the amount of the government’s loss) and civil penalties per false claim. For whistleblowers, identifying fraudulent billing is often the key to building a strong qui tam case.
We see fraudulent billing not as abstract misconduct but as a daily reality that affects patient trust and public resources. Exposing these schemes is one of the most direct ways whistleblowers can make a difference.
