Violations of Medicare laws and the Medicare
Fraud and Abuse Statute also constitute violations of the False Claims Act. Hospitals, nursing homes, doctors,
home health care agencies, durable goods providers, pharmacies, and
laboratories that seek and receive reimbursement for Medicare and
Medicaid funds are Government contractors subject to the False
Claims Act.
Healthcare workers
and families of nursing home or hospital patients should pay
particular attention to the services provided. Not only can this
improve the healthcare for patients and loved ones, but it also
helps ensure that public Medicare and Medicaid monies are properly
spent in accordance with the law and good medical practice.
Billing for services not rendered,
misrepresenting the type of goods or services rendered, or
misrepresenting the nature of the patient's illness can trigger liability
under the False Claims Act. Likewise, failing to provide
correct data on annual hospital or nursing home cost reports that
must be provided to the Government will violate the law, if the
errors were done knowingly or intentionally. In addition, hospitals and nursing
homes that provide substandard care may also be in violation of the
False Claims Act.
The largest False Claims Act settlement in 2001
involved fraud by pharmacies. Pharmacy-related violations
could include the following:
1. Partially filling prescriptions,
but charging as if a full prescription was provided.
2. Providing kickbacks to a medical
provider in order to induce the provider to prescribe certain drugs.
3. Prescribing unneeded
medications, drugs, or treatment that are not a medical necessity.
4. Charging Medicare or Medicaid
patients a higher rate than others for the same prescription.
5. Knowingly providing defective
products or services.
6. Falsely diagnosing a more severe
ailment than the one the patient actually has, known as "upcoding" a
diagnosis, thereby justifying a more expensive drug therapy or other
treatment than that which the patient's health really requires.
7. Inappropriate changes in
patients' prescriptions from one drug to another as a result of
kickbacks or for other improper reasons.
8. Falsely reporting drug research
grant information to government agencies.
