Healthcare Fraud Explained

The threat of healthcare fraud is ever present, and on the rise. It’s costing the government, and by extension us tax payers, billions of dollars. Because it puts our well-being at risk as well as our financial future, healthcare fraud is especially nefarious and more must be done to expose those who abuse the power of their medical knowledge to the detriment of others.

With the help of brave whistleblowers, the government has been able to recover billions through the False Claims Act - $13.6 billion of which was recovered in cases of fraud against federal health programs such as Medicare and Medicaid. However, healthcare fraud is not always easy to spot.


What is healthcare fraud?

Often, behavior that comes to seem normal or even expected in hospitals is actually illegal. Some of the more common healthcare fraud schemes include:

  • When false statements are submitted to the government for procedures that were never rendered.
  • Soliciting or taking bribes, known as kickbacks, in return for referrals, or arranging for the purchase of items paid for by federally funded programs.
  • When procedures are billed as more expensive than they actually are (known as “upcoding”).
  • Billing each step of a procedure as if it were a separate procedure (known as “unbundling”).
  • Billing for procedures that were performed unnecessarily.
  • Waiving co-pays to encourage patients to seek treatments they might not otherwise have opted to receive.
  • Prescribing generic forms of medication, and billing the government for name brands.
  • Inflating the reported costs to Medicare of expenses they reimburse.
  • Not adhering to FDA regulations.
  • Knowingly providing defective medical devices, or drugs less safe then advertised.

What to do if you witness fraud?

If you are a healthcare worker reporting healthcare fraud is your duty. Healthcare fraud is prosecuted most frequently under the False Claims Act, which prevents the government from being overcharged and sold substandard goods; it also protects the “whistleblowers” that bring this fraud to light.

If you come forward with information about healthcare fraud, the False Claims Act protects your identity and safeguards you from retaliation by your employer.

For more information, check out these six tips for healthcare workers who would like to report Medicare and Medicaid fraud.

If you have knowledge of health care fraud, you should come forward immediately as there is a statute of limitations on these cases. It is best to consult an attorney with whistleblower experience as soon as you learn of the possibility of fraud so that you get the best advice on how to proceed.

How Morgan & Morgan can help

Our whistleblower attorneys, James D. Young and John A. Yanchunis, are part of the Complex Litigation Group within Morgan & Morgan- which means they count on the substantial resources of one of the leading plaintiffs’ law firms in the country. They head a team of former FBI investigators with more than 100 years of combined experience who are dedicated to persecuting fraud.

With over 300 lawyers and a support staff of over 1,400 people, Morgan & Morgan has helped more then 75,000 clients in the past 25 years. Unlike other, smaller, firms, we can afford to take on the costs of going head to head with big-name defendants. We’ve taken on medical device makers, large insurance companies, and other for-profit businesses, ultimately making them accountable for their actions.


Attorneys Young and Yanchunis have substantial experience with False Claims Act/ Qui Tam Litigation, specifically health care fraud.  They’ve been involved in complex cases and have been able to recover over $1 billion dollars for clients, most recently in a lawsuit against Adventist Health System. Additionally, our whistleblower attorneys maintain the highest standards when it comes to selecting cases, which means they’ve built a reputation for handling high-quality cases in which the government is more likely to intervene - which improves a case’s chance.

If you know someone committing healthcare fraud, and want more information on what you can do to stop it, contact the Complex Litigation Group Today.