Fraud in the healthcare, pharmaceutical, and durable medical equipment industries is significant and contributes substantially to rising healthcare costs. President Biden spoke passionately about it in his State of the Union address.

Sadly, fraud was pervasive during the COVID pandemic.

Some typical fraudulent schemes and techniques we have experienced in government healthcare programs include:

The Anti-Kickback Statute and Stark Laws were created to prohibit providers from receiving potential monetary benefits that could influence their medical treatments instead of focusing on the patient’s well-being.

Upcoding includes overstating the time, procedures, or person performing the treatment to bill for more services or at a higher rate.

Risk Adjustment payments elevate provider support for people with costly diseases. Some examples include falsifying claims, overstating a patient’s condition, and performing additional or redundant tests despite past diagnoses.

Unbundling occurs by billing a singular service as if it were multiple procedures. By billing for procedures separately and charging numerous services separately that are generally covered by a single, comprehensive CPT code the provider receives greater revenue.

Billing for services not provided violates the False Claims Act by billing for services that were not performed, or charging for supplies and equipment that were never delivered.

Medically unnecessary services may include avoidable inpatient admissions, advanced imaging, needless tests, or lab work.

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