Types of Medicare and Medicaid Fraud

Companies that commit Medicare and Medicaid fraud stand to make a considerable profit from their unlawful actions.

This being the case, there are many ways in which an organization may attempt to defraud the government and taxpayers. Vigilant citizens should be on the lookout for any questionable billing practices and remember that their employers may not retaliate against them for investigating fraud.


Whistleblower lawsuits in recent years have involved the following types of Medicare and Medicaid fraud:

  • Phantom BillingPhantom billing occurs when a hospital or healthcare organization bills Medicare or Medicaid for tests or services not performed.
  • Billing for Unnecessary Services – Healthcare organizations may be subject to liability under the False Claims Act for billing for services or procedures that are not medically necessary, such as providing patients with unnecessary stent implants.
  • Kickbacks – It is illegal for healthcare providers to make or accept payments for referring, recommending, or arranging for the purchase of items paid for by federally-funded programs. The healthcare organization making or receiving the bribes can be held liable for damages under the False Claims Act.
  • Up-Coding – Up-coding occurs when a hospital or other healthcare organization fraudulently alters diagnosis or treatment codes to receive higher reimbursements from Medicare or Medicaid.
  • Unbundling – Unbundling occurs when a medical lab or healthcare facility bills Medicare or Medicaid separately for related services to receive a higher rate of reimbursement. Instead, the facility should use a billing code that bundles the related services as required by Medicare and Medicaid.
  • Double Billing – It is illegal for hospitals and other healthcare organizations to charge twice for a service or procedure that was only performed once.
  • Waiving Co-Pays – Hospitals or other healthcare organizations may be liable for damages under the False Claims Act if they waive co-pays to encourage patients to seek treatments that they might otherwise opt not to receive.
  • Substitution of Generic Drugs – It is illegal for pharmacies to bill Medicare or Medicaid for the cost of name-brand prescriptions when a generic drug was given to the patient.
  • Submitting Fraudulent Cost Reports – Medicare reimburses hospitals, nursing homes, and other healthcare organizations for certain costs, in addition to paying for individual procedures and treatment. Healthcare organizations that knowingly inflate costs or mischaracterize costs as reimbursable may be held liable under the False Claims Act.
  • Noncompliance with FDA Regulations – Pharmaceutical companies, medical device manufacturers, and medical equipment makers must comply with a long list of FDA rules and regulations with regard to obtaining FDA approval. Furthermore, these companies must certify that the drugs or medical devices are manufactured in accordance with current Good Manufacturing Practice (cGMP) regulations. Violations of FDA rules and regulations may subject pharmaceutical, medical device, and medical equipment companies to liability under the False Claims Act.
  • Knowingly Providing Defective Medical Products or Services – Under the False Claims Act, drug companies and medical device manufacturers can be held liable for knowingly producing or providing products and services that are defective.

If you have evidence, or believe you have knowledge, of Medicare and Medicaid fraud, please contact us through the form on the right or call us at the above number. All of your communications will be kept confidential, and our experienced whistleblower attorneys are happy to answer any questions you may have.