Probably the clearest example of fraud by health care providers involves billing for services that were never delivered to patients. The basic scheme can involve as many variations as there are treatments.
For example, some physicians bill Medicare or Medicaid for diagnostic procedures they never performed, physical therapists bill for sessions that never took place, and nursing homes might bill for supplies that were never actually purchased or used. There is often some falsification of records to support improper billings.
Billing for unnecessary procedures or services that have been added to a bill for legitimate charges is another type of false claim. The government also has held clinical laboratories liable when they induced physicians to order unnecessary add-on tests by including the extra test in a standard blood chemistry panel at minimal or no extra charge to the physician. The lab then bills Medicare for the additional test without the doctor's knowledge. When the physician doesn't have the option of ordering the standard panel without the extra test, the lab may be liable for claims submitted for the extra test.
National Health Laboratories Inc. paid the federal government and state Medicaid programs $111 million to settle a whistleblower case brought by a Phillips & Cohen client. The lawsuit charged the company billed Medicare for blood tests added to the standard panel of blood chemistry tests even though doctors had not ordered the extra tests and they were medically unnecessary.
Columbia/HCA (now known as HCA) paid $92 million to set a whistleblower lawsuit brought by two emergency room doctors represented by Phillips & Cohen. Their lawsuit stated that each time a physician ordered a complete blood count (CBC) for a patient in the emergency room or outpatient services, Columbia hospitals also billed Medicare for additional blood chemistry tests, known as "CBC indices," that doctors hadn't ordered. In addition, the lawsuit said, when a doctor ordered a "chemistry profile" for a patient in the emergency room or outpatient services, the hospitals also charged for various other blood tests that had not been ordered.