Medicaid and Medicare Fraud

Medical bills and expenses can be crippling in today’s world, especially for older people who need more frequent check-ups, procedures, or extensive surgeries. Fortunately, there are services available for elderly people who need help paying for their medical bills—Medicaid and Medicare. But these insurance providers are often widely abused by nursing homes and doctors who treat older patients, resulting in one of the most insidious forms of financial elder abuse.

Because there are so many people over the age of 65 living in California, our state’s nursing homes are often full of elders who need extra day-to-day care, or who are too sick to live on their own. And unfortunately, abuse is rampant in many of these institutions, financial elder abuse lawyers in San Francisco report. Medicaid and Medicare fraud schemes are particularly prevalent because many older citizens rely on these government-funded services to handle all their medical needs, which can be extensive and costly.

According to research done by the National Adult Protective Services Association, 1 in 9 senior citizens reported being victims of abuse, neglect, or exploitation in the last year. Additionally, 1 in 20 senior citizens believed themselves to be victims of financial mistreatment. But only 1 in 44 cases of financial abuse are actually brought forward by the victims or their families, and the perpetrators are taken to court. The lack of awareness and action may be due in part to the fact that nearly 90% of all elder abusers are people that the victims are familiar with, and trust with their financial and physical wellbeing. This could be anyone from a close friend to a family member to a member of the hospital or nursing home staff.

How Medicaid / Medicare Scammers Operate

In financial abuse cases involving Medicaid or Medicare, nursing home or a care center for the elderly will request reimbursement from the insurance providers for services that they have not performed or have performed improperly or incompletely. Often, doctors, nurses, and home administrators can steal millions this way, relying on their elderly patients not to follow up or to question the bills to their providers.

In another, similar, scheme scenario, doctors and administrators will overmedicate patients, prescribing antipsychotics and other unnecessary drugs, usually with a calming or sleeping agent, to sedate patients unnecessarily. This is done solely so that staff members do not have to deal with the senior citizens as much, San Francisco financial elder abuse lawyers say.

But this type of financial elder abuse doubly threatens older Californians as victims. Those who are targeted individuals are not receiving proper medical care, even though they are paying for it through their insurance provider. And any other person who relies on government-funded programs like Medicaid and Medicare is being cheated out of funds that they so desperately need to cover medical expenses.

10 Signs and Examples of Healthcare Fraud 

Healthcare fraud, including Medicaid and Medicare fraud, is not always easy to discern, as it is most often perpetrated by the staff of hospitals, nursing homes, assisted living facilities, and other institutions. These departments are made up of potentially dozens of employees, each of whom may or may not have a hand in the fraud, who can obscure their deception through paperwork and administrative red tape. As such, if you suspect that someone you care about has been the victim of healthcare fraud, you should consider speaking to a San Francisco financial elder abuse lawyer.   

Examples of Healthcare Fraud 

• Charging for services not rendered: Occurs when the perpetrator submits a claim to Medicaid or Medicare for a service that was not rendered to the patient
• Rendering unnecessary medical services: Occurs where the perpetrator performs an unnecessary medical procedure solely to bill Medicaid or Medicare for it
• Double billing for medical care: Occurs when the perpetrator submits multiple claims for a medical service that was rendered only once
• Kickbacks for referrals or prescriptions: Referral kickbacks occur when one service provider offers an incentive (often cash) to another service provider to refer patients to their office. Prescription kickbacks occur when a pharmaceutical representative offers an incentive to doctors to prescribe a particular medication. 
• Overmedication: Occurs when a service provider overmedicates a patient either to chemically restrain them or to submit claims for payment for the drugs used. 
• Upcoding: Occurs when the perpetrator assigns an inaccurate billing code to a service to increase reimbursement
• Unbundling: Occurs where the perpetrator bills multi-step procedures separately rather than as a single procedure, which can often result in higher payments from Medicaid and Medicare
• False diagnoses: Occurs where the perpetrator intentionally misdiagnosis a patient’s condition to justify the need for medically unnecessary tests and procedures
• Billing a covered service as a non-covered service: Occurs where the perpetrator bills the patient for a service that is covered under their insurance plan. 
• Misrepresenting dates of service: Occurs when the perpetrator bills one office visit as multiple office visits to secure increased reimbursement. 

Signs of Healthcare Fraud

• Evidence that inadequate care has been provided (e.g., bedsores or pressure ulcers, unsanitary conditions, malnutrition or dehydration, etc.)
• Evidence that incorrect medication has been given 
• Diagnoses that are inconsistent with the patient’s symptoms
• Multiple bills for the same medical service
• Misrepresentations of the provider, date, or location of services 
• Waived co-payments and deductibles 
• Incorrect information on paperwork explaining healthcare benefits
• Charges for services or medications that were not rendered or provided
• A sudden, unexplained increase in the cost of a procedure that has been rendered previously 
• False use of the patient’s medical information 

While each of the above signs of healthcare fraud could also be the result of honest mistakes, multiple or repeated instances are stronger evidence of financial elder abuse. If you need help identifying what you believe could be healthcare fraud, please contact a San Francisco financial elder abuse attorney.

Contact a San Francisco Financial Elder Abuse Attorney Today

If you suspect elder financial abuse of any kind, contact an attorney immediately. At the Evans Law Firm, Inc., our San Francisco financial elder abuse lawyers represent clients who have had their Medicaid or Medicare insurance coverage abused through unnecessary or fraudulent billing. Contact one of the attorneys at the Evans Law Firm to discuss your case today at www.evanslaw.com or 415.441.8669.