Whistleblower (Qui Tam) Law Health Care Fraud

Health care fraud is in the news virtually every day with cases ranging from billing for procedures that are not medically necessary to billing for services not rendered or “upcoding” services to a higher level in order to increase revenues. This type of fraud costs the government and, by extension, U.S. taxpayers, about $60 billion a year.

Ashcraft & Gerel has significant expertise in the area of health care fraud, including:

Billing for Unnecessary Medical Services

Doctors–and other medical professionals–may perform procedures that are medically unnecessary to increase their income and profits. These cases have serious consequences for patients and for government health benefit programs, like Medicare and Medicaid.



Medicare and Medicaid reimburse providers based upon CPT (for physician practices) and DRG (for hospitals) codes that are assigned by the American Medical Association to different procedures and office visits. Providers commit fraud when they “upcode” a procedure, office visit or hospital stay to a higher level CPT code to increase their reimbursement.

Billing Medicare or Medicaid for services not provided violates the FCA as well.


It is a violation of the federal Antikickback Statute (“AKS”) for hospitals, nursing homes, or other providers to offer or pay doctors and other medical professionals money or other items of value (such as free office space or staff) in exchange for the referral of patients. Similarly, doctors are prohibited by the federal Stark Law from referring patients to hospitals or other institutional providers in which they have a financial interest.