Services Not Rendered

One of the most common and straightforward forms of healthcare fraud involves submitting claims to the government for reimbursement for services that were not actually administered to Medicare or Medicaid patients. This type of fraud is tempting to physicians because it is very easy to commit; therefore various types of healthcare providers have been sued by the government for it including nursing homes, physical therapists, and home health aides. In addition to services not provided, some healthcare providers create “ghost patients” and bill the government for services for patients who do not exist. Any submission to Medicare or Medicaid for reimbursement for a service not rendered to a real patient may violate the FCA.

Since this type of fraud is easy to commit, it is also very easy for jurors to understand. For this reason, FCA cases of this sort frequently settle in the early stages of litigation.

Example

In one of the more brazen violations of the FCA, Intercare Health Systems Inc. (formerly known as City of Angels Medical Center) submitted claims to Medicare for services that were not actually given to patients. The company paid “recruiters” at Los Angeles homeless shelters to deliver homeless people to hospitals, regardless of whether or not they actually needed medical treatment. Then, the company billed Medicare for services not actually rendered to the patients, or for those not medically necessary. The company ultimately agreed to a consent judgment of $10 million for violating the FCA and the Anti-kickback Statute.

Example

In May 2010, a Pennsylvania physician was sentenced to 12 months and 1 day in prison for health care fraud. Previously, the physician agreed to pay $3.3 million to resolve his liability under the FCA. The civil settlement resolved allegations that from January 2003 to August 2008, he submitted claims to Medicare, TRICARE, and the Federal Employees Health Benefits Program for services not rendered to his patients either because the physician was not in the office or the patients were in hospitals under the care of other physicians on the dates claimed. He also regularly billed for treatments that his patients never received.

Example

In June 2010, a Pennsylvania pediatrician was sentenced to 96 months incarceration and ordered to pay $7.1 million in restitution after pleading guilty to charges of health care fraud, mail fraud, and forfeiture. From 2003 through 2009, the pediatrician submitted fraudulent claims to Medicaid, TRICARE, and private insurance companies for services not rendered. The investigation involved the South Carolina Attorney General's MFCU and Insurance Fraud Division, and the Cumberland County, Pennsylvania District Attorney's Office.

Example

In November 2009, a podiatrist was sentenced to 36 months' incarceration and ordered to pay $5.4 million in restitution for health care fraud and making false statements. The podiatrist systematically billed Medicare for routine foot care not covered by Medicare and billed for services not rendered, such as costly nerve conduction tests and abscess drainages. In addition to his sentencing, this individual surrendered his license to practice podiatry in the state of New York.