The False Claims Act permits private individuals to sue their employer on behalf of the United States Government when you have information of your employer defrauding the Government. One example would be Medicare Fraud. If you are a medical coder and you have been instructed by your employer to code and/or bill in a manner which is contrary to Medicare Guidelines, you may have a False Claims Act action against your employer.
An employer may instruct a medical coder to “upcode” a regular diagnosis or procedure to a more serious diagnosis or procedure. Since payment is many times based upon the various degrees of diagnosis and procedures, an employer will seek to increase profits by “upcoding” procedures and diagnosis. For example, a billing service may code an emergency room visit as a “critical” visit when in reality the visit was "non-critical."
An employer may also instruct a medical coder to “unbundle” medical procedures to increase profits. Instead of billing for one procedure, the medical coder will “unbundle” the one procedure into multiple procedures. These multiple procedures will be billed out separately and will cost the government more money in payouts as opposed to the payment for one single procedure. For example, a rotator cuff shoulder surgery is one procedure; however, that one procedure involves several separate individual procedures. A medical billing service or provider may attempt to separate the individual sub-procedures to maximize profits contrary to Medicare guidelines.
Billing For Services Not Performed
The most obvious example of Medicare Fraud is when a medical provider bills for services never performed. A medical provider may bill for products that were never given to the patient. Or the medical provider may bill for hours that were never worked by an employee. For example, a home health aide may have only worked at a home for one hour and the billing indicates she worked two hours.