One of the most common health care fraud schemes is billing government health care programs for services that were never actually provided to patients.  Examples of this scheme of fraud can include physicians billing for medical tests that were never performed, or a home health care company submitting claims to Medicare for home health care visits that never occurred.

Examples of successful cases:

  • In Ohio, a managed care company agreed to pay $26 million to settle a claim that the company billed Medicaid for services that were not provided. Over a period of at least 5 years, the company billed fraudulently billed Medicaid for case management services that were not provided. The company knowingly did not provide required screening, assessment and case management for adults and special needs children. Subsequently, the company submitted false data to the state of Ohio to make it appear as if these required services were actually provided.
  • In Nevada, an anesthesiologist was found liable for submitting over 3,500 false or fraudulent claims totaling $421,000 in reimbursements from Medicare. The anesthesiologist submitted claims for services rendered for consultations that were either not requested or not provided.
  • Odyssey Healthcare agreed to pay $25 million to settle a False Claims Act whistleblower suit. Odyssey Healthcare provides hospice services, among others, in 27 states. Medicare can pay up to several hundred dollars a day for continuous home health services as opposed to routine services  It was alleged that Odyssey Healthcare billed Medicare for home health services that were unnecessary or not even performed.
  • APS Healthcare Midwest agreed to pay $13 million to settle a False Claims Act suit. APS Helathcare was accused of charging Medicaid for services that were not rendered, specifically charging for specialty services related to disease and case management, when these services were not actually performed, leaving those in need without the care required.

Caresource, an Ohio based managed care organization, agreed to pay $26 million to settle a lawsuit brought under the False Claims Act. Caresource was accused of falsifying records showing that baseline health assessments of special needs children were conducted before further treatment started, when they in fact had not conducted the health assessments. Medicare pays for these baseline health assessments because it is more efficient to identify and treat any health issues if they are found earlier as opposed to later.