Medicaid & Medicare Fraudulent Billing Qui Tam Cases

Understanding Healthcare Fraud Under the False Claims

False Claims Act (“FCA”) qui tam cases involving Medicaid and Medicare fraudulent billing take many forms. Whistleblowers frequently report conduct such as billing for services never rendered, providing care so inadequate it has little or no medical value, falsifying credentials, upcoding, unbundling, or manipulating patient data.

Below is a structured overview of the most common violations that lead to Medicaid and Medicare whistleblower actions.

1. Treatment-Related Fraud Schemes

Healthcare providers can face FCA liability when they submit claims for treatments or services that do not meet required standards or were never delivered.

A. Total Neglect or No Services Provided (Classic False Billing)

Submitting claims for examinations, procedures, or services that were never performed is one of the most straightforward forms of Medicare/Medicaid fraud.

Examples include:

• Billing for diagnostic tests never ordered
• Charging for procedures never performed
• Submitting claims tied to kickback-driven referrals

Such conduct creates clear FCA liability for knowingly submitting false reimbursement claims.

B. “Worthless Services” Billing

Providers may face FCA exposure when services are so deficient they have no medical value.

Examples include:

• Failing to feed, hydrate, or supervise patients
• Allowing preventable deterioration, illness, or injury
• Providing care grossly below accepted medical standards

Even if some services were delivered, courts may deem the overall care “worthless.”

C. Inadequate or Inferior Services

In some schemes, facilities reduce staffing, equipment, testing, or specialist referrals to increase profit — especially in per-diem reimbursement environments.

These practices may violate:

• The Nursing Home Reform Act
• Medicare and Medicaid participation standards
• Federal quality-of-care regulations

Submitting claims for inadequate, substandard care can constitute a false claim.

D. Failure to Meet Required Standards of Care

Healthcare providers must follow federal and program-specific quality-of-care standards.

FCA violations may arise when:

• Facilities expose patients to unreasonable risk
• Preventable harm occurs due to inadequate precautions
• Providers fail to implement required oversight or safety measures

Failure to meet these standards — and still billing Medicaid or Medicare — can trigger liability.

E. Aggressive or Medically Unnecessary Treatment

Whistleblower claims frequently involve:

• Ordering unnecessary tests
• Referring patients for unwarranted procedures
• Performing high-frequency services solely to increase billing

If Medicare/Medicaid reimburses these unnecessary services, FCA liability may result.

2. Misrepresentation of Provider Credentials

Another area of medical billing fraud cases in the health care system occurs when a healthcare provider submits a false claim to health insurance providers under the FCA for misrepresenting the credentials of the person that provided the services. These cases typically involve a provider representing to the government that someone eligible for reimbursement provided the service when it was actually performed by a person precluded from reimbursement. Cases involving misrepresentation of credentials may involve a wide variety of factual scenarios, including providing reimbursement claims with incorrect provider identification numbers (“PIN”), billing for services rendered by an unlicensed physician, or falsely representing that a teaching physician was present for procedures provided by a university’s medical school in accordance with applicable Medicare regulations.

3. Upcoding and Improper Coding of Service

When submitting a claim for Medicare reimbursement to the government, the claimant must provide documentation and medical records that support the claim. Appropriate documentation typically involves correctly coding certain services to enable the government to reimburse the healthcare provider at the proper rate. Coding accuracy is a major concern for all physician offices, clinics, and hospitals because incorrect coding can have severe financial and even criminal consequences. As a result, healthcare providers, such as hospitals and physician groups, will often contract with outside vendors to perform coding and billing services. The physicians send a copy of their charts to the vendors, which, in turn, code the services or procedures performed and submit a claim for reimbursement to Medicare. If the vendor submits reimbursement claims for a higher billing code than what is justified by the physician’s charts, then the vendor may be liable for submitting false claims.

4. Unbundling of Services

Medicare requires certain related services to be bundled into a single claim.

Fraud occurs when providers:

• Bill once for the bundled service
• Then unbundle the same service into multiple claims
• Collect reimbursement twice (“double billing”)

Intentional unbundling is a well-recognized FCA violation.

5. Misrepresentation of Patient Data or Populations

Many physicians provide services for patients either in a nursing home, via telemedicine, where the patient resides, or in the physician’s office. Due to complex interactions between nursing homes and physicians, billing inaccuracies frequently occur that could translate into false claims.

If you have information about fraudulent billing practices, you may be able to file a qui tam whistleblower lawsuit under the False Claims Act.

Notice

This website is designed to provide general information only. This information is not and should not be construed to be legal advice. The transmission of the information found on this website also does not result in the formation of a lawyer-client relationship.

You should be aware that qui tam claims are subject to a Statute of Limitations. The area of limitations periods is complex. There are also first to file rules, public disclosure bars, original source issues, and varying limitations in pursuing retaliation claims. If you wish to pursue your claims, you should promptly seek the opinion of an attorney regarding the merits of your qui tam claim and the applicable statute of limitations.