Types of Medicare & Medicaid Fraud
Healthcare fraud costs taxpayers tens of billions of dollars a year. These are the patterns that most often give rise to False Claims Act cases.
Upcoding and billing for services not rendered
Upcoding happens when a provider bills for a more expensive service or procedure than the one actually performed — for example, coding a routine office visit as a complex, lengthy consultation. Closely related is billing for services that were never provided at all. Both cause government programs to overpay, and both are among the most common forms of healthcare fraud under the False Claims Act.
Kickbacks and the Anti-Kickback Statute
The federal Anti-Kickback Statute prohibits paying or receiving anything of value to induce referrals of services covered by Medicare or Medicaid. Kickbacks can take many forms: cash, lavish gifts, sham "consulting" fees, or free goods. When claims result from an illegal kickback, they can also violate the False Claims Act. These schemes are dangerous to patients because they let financial incentives — rather than medical need — drive care.
False certifications of medical necessity
Government programs generally pay only for care that is medically necessary. Fraud occurs when providers certify that treatments, tests, or equipment were necessary when they were not — ordering unnecessary diagnostic tests, prescribing unneeded equipment, or admitting patients who do not require inpatient care. Each false certification can support an FCA claim.
Phantom billing and ghost patients
"Phantom billing" refers to charging for services, supplies, or visits that never occurred. "Ghost patients" are billings submitted under the names of people who were never treated, are deceased, or do not exist. These schemes often surface in billing records that insiders — billing staff, coders, and administrators — are uniquely positioned to recognize.
Home health and hospice fraud patterns
Home health and hospice care are frequent targets because eligibility depends on clinical judgments that can be manipulated. Common patterns include certifying patients as homebound or terminally ill when they are not, billing for visits that did not happen, and enrolling ineligible patients to capture per-patient payments. Because these programs serve vulnerable people, the fraud is especially harmful.