Many people go to the doctor or to a hospital in California. It is inevitable that people will get injured or sick and require medical treatment. As these people know, medical treatment is also very expensive. However, if the person has health insurance, most likely they will not need to pay the entire bill. Many people receive Medicare as their form of insurance. Ultimately, the hospital or clinic will bill Medicare for the expenses, but in many cases, they negotiate with Medicare for how much the hospital will actually receive.
Many times, it is less than what the total medical bill, and therefore, hospitals have the incentive to change documentation to bill Medicare for more than what was actually performed. This is illegal, but one major medical provider recently was accused of doing this.
A whistleblower who was a registered nurse informed the government that Prime Healthcare was up-coding their billing to Medicare in a scheme to increase Medicare payments. Up-coding is essentially making a diagnosis seem worse than it actually is on the bill sent to Medicare. The case recently settled with Prime Healthcare paying $65 million.
The whistleblower received approximately $17 million of that settlement for her efforts in exposing this practice through the False Claims Act. This allows private citizens who expose these practices to receive up to 30 percent of any settlement or judgment.
There are many hospitals and clinics in California that are operated by various healthcare systems. While these healthcare systems are in the business of helping people get better, they are also trying to make money. So, some will falsify their billing or do other things to try and receive more money from Medicare.
The government has a major interest in ensuring that this does not occur, and people who report this illegal practice could receive significant compensation for doing so. Experienced attorneys understand the complicated process of these cases and may be able to guide one through it.