The investigation before qui tam

8 minute read

On the topic of human ambition, Ecclesiastes 1:9 is credited with the saying: “What has been will be again, what has been done will be done again; there is nothing new under the sun.” This was allegedly said in the mid-10th century B.C.

Healthcare fraud is certainly not new. However creative a fraud scheme may seem, chances are it’s been done. Healthcare fraud is a known high-risk area that affects the healthcare industry, government officials, taxpayers, insurers, premium-payers, and trusting patients who are at significant risk of injury in some fraud schemes. Healthcare attorneys, compliance officers, and operators around the nation have the insurmountable task of spotting what these fraud schemes look like and how they are being carried out so they can create and implement oversight processes to detect and prevent them. Additionally, if left unattended, healthcare fraud can potentially cause a healthcare institution’s financial demise due to the strength of federal laws surrounding this subject and the hefty penalties accompanying them.

Healthcare fraud, like any fraud, demands that false information be represented as truth. An all-too-common healthcare fraud scheme involves perpetrators who exploit patients by entering their medical records’ false diagnoses of medical conditions they do not have or more severe conditions than they actually have. This is done so fraudulent insurance claims can be submitted for payment. Unless and until this discovery is made, these false or inflated diagnoses become part of the patient’s documented medical history.

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