What is Phantom Billing?
By Berger Montague Attorneys.
Medicare fraud broadly refers to any individual, company or corporation who acts intentionally to steal money from the federal government. “Phantom billing” is a specific kind of Medicare fraud, as well as the most common.
Phantom billing occurs when healthcare providers submit claims for reimbursement to the government for services or procedures they did not perform, or for higher-priced products or services than those provided to their patients.
Further, phantom billing can occur when healthcare providers submit claims for procedures that were medically unnecessary, which they administer to patients who are either healthy or never required the procedure in the first place.
Healthcare providers are not always the sole offenders and sometimes solicit patients who involve themselves in Medicare fraud schemes in exchange for monetary kickbacks.
The Frequency of Phantom Billing
Phantom billing occurs every day, as such offenses take many forms and are often hard to catch. Instances of this type of Medicare fraud include:
- A healthcare provider who submitted claims for power wheelchairs his patients neither needed nor received;
- A physician who was found to have billed the federal government for hundreds of fillings and root canals, apparently performed on patients who had no teeth to even treat; and
- A medical equipment company who submitted false claims for equipment like oxygen generators and breathing machines that was materially different from and more expensive than what patients actually received.
The Costs of Phantom Billing
Phantom billing most directly affects programs like Medicare, whose monetary supply is fraudulently spent, and whose resources are then unnecessarily utilized.
Because taxpayers are the ones who pay for these programs, the population as a whole is also affected when fraudulent claims produce higher healthcare costs for everyone.
Likewise, patients who require Medicare services suffer when resources from these systems are drained, resulting in services that must be cut and patient coverage that must limited.
How to Report Phantom Billing
Under the federal False Claims Act (“FCA”), the U.S. government investigates healthcare providers who defraud the government. The FCA is the primary weapon used to fight fraud against the U.S. government, and many states have similar laws to protect themselves against fraud.
There are different ways to report Medicare fraud, and they vary depending on who the individual reporting the fraud is relative to the individual or entity committing the crime. For example, those who report their own employers with firsthand knowledge of fraud are known as “whistleblowers.”
The False Claims Act provides financial incentives for individuals who report fraud to the government, permitting whistleblowers to share in the government’s monetary recovery. Specifically, whistleblowers who bring successful False Claims Act suits can be rewarded with anywhere from 15 to 30 percent of what the government ultimately recovers from the providers.
Similarly, under the qui tam provisions of the False Claims Act, private citizens with first-hand knowledge of government fraud can, after consulting with an experienced False Claims Act attorney, file, and benefit from, lawsuits on behalf of the United States. Qui tam suits are filed under seal to protect the reporting individual’s anonymity and preserve the integrity of the investigation.