Fraud Tales: Fraud Investigation Uncovers Medicare and Medicaid Fraud

Government payments to providers under the Medicare and Medicaid programs are based on an “honor billing system,” meaning it is up to providers to honestly and accurately bill the government for services or goods provided.  Not surprisingly, fraud investigations routinely uncover fraudulent activities that cost the government billions of dollars each year.

“As a forensic accountant, I have been asked to investigate Medicare and Medicaid billing fraud both by the government and by private companies that suspected some of their employees were involved in fraudulent activities,” said David Anderson, principal of David Anderson & Associates, a Philadelphia forensic accounting firm that provides a full range of fraud investigation and fraud deterrence programs in the Delaware Valley.  “My fraud investigations have unearthed some of the most common Medicare and Medicaid fraud schemes as well as some that were quite creative.”

Medicare is a federal government health insurance program established in 1966 to provide health insurance to people 65 and older and to certain disabled people, said Anderson, who also is a Certified Fraud Examiner in Philadelphia.  The program is funded through payroll tax deductions and administered by the federal government.  Medicaid is a government program established in 1965 to provide health insurance to low-income individuals in all 50 states, Anderson said.  Medicaid is funded jointly by the state and federal governments and administered by the states.

The so-called “honor billing system” puts the onus on healthcare providers, including durable medical equipment suppliers and pharmacies, to truthfully bill the two agencies for services and goods, said Anderson, whose firm provides a full range of forensic accounting services in Philadelphia and the Delaware Valley.  As a result, Medicare and Medicaid billing fraud generally is detected only after the fact, based either on tips from whistleblowers or after-the-fact data analysis that detects unusual billing patterns, he said.

Among the fraudulent Medicare and Medicaid schemes Anderson’s fraud investigations have uncovered are:

  • Upcoding Schemes: These frauds involve healthcare providers who  charge for a more expensive procedure than was actually performed, said Anderson, a forensic accounting expert in Philadelphia.  For example, he said, because Medicare pays more for a comprehensive annual physical exam than it does for a routine office visit, some providers will improperly bill a routine office visit as a comprehensive annual physical exam to receive the higher fee.  Or, a physical therapist may schedule a group session to provide physical therapy for multiple individuals at the same time, but bill Medicare/Medicaid for individual treatments at a much higher rate.
  • Unbundling Schemes: This fraud occurs when a group of medical tests typically billed as a single procedure are instead billed individually, thereby increasing the total fees for the tests.  An excellent example of this, said Anderson, a Certified Fraud Examiner in Philadelphia, is the Chemistry Panel and Complete Blood Count test.  This panel includes tests for cholesterol, triglycerides, blood glucose, calcium, potassium, iron, and complete blood count, as well as a number of other tests.  By performing a Chemistry Panel and Complete Blood Count but billing for each test individually, the laboratory can make a much higher fee for its services.
  • Non-existent Services Schemes: These fraud schemes occur when a healthcare provider bills for goods or services never provided, Anderson  In his work as a forensic accountant, Anderson uncovered a dentist who billed Medicaid for removing the same tooth from a patient four different times.  Another example, he said, is a gynecologist who billed for performing an internal pelvic exam on a man.  Anderson, a forensic accounting expert in Philadelphia, said Medicare and Medicaid recently have cracked down on home health care companies, for example, for providing eight hours of home health care but billing for 24 hours of care.
  • Medical Equipment Schemes: These schemes have many variations but generally involve providers who bill for new medical equipment but deliver used equipment, or who bill for equipment that was never delivered at all.
  • Prescription Drug Schemes: There also are more variations on this scheme, which include pharmacies that provide patients with generic drugs, but bill for more expensive name brands, or pharmacies that bill for a higher dosage or number of pills than was provided to the patient.

“The FBI estimated that in 2012, Medicare fraud alone cost the government as much as $250 billion for the year,” said Anderson, a forensic accountant and Certified Fraud Examiner in Philadelphia.  “Add to that the many billions of dollars lost to Medicaid fraud annually, and you can see how big a problem this is.  Hopefully, both federal and state governments will implement new procedures to reduce Medicare and Medicaid fraud in the future.”

This Tale of Fraud is another in a series of occasional posts that explores actual frauds perpetrated against businesses, non-profits or government offices and agencies and the fraud investigations that uncovered the illicit activities and, when possible, the fraud deterrence measures that could have prevented them.

If you require the services of a Certified Fraud Examiner in Philadelphia or any other forensic accounting services in Philadelphia and the Delaware Valley, please contact the Philadelphia forensic accounting firm of David Anderson & Associates by calling David Anderson at 267-207-3597 or emailing him at

About David Anderson & Associates

David Anderson & Associates is a Philadelphia forensic accounting firm that provides a full range of forensic accounting services in Philadelphia and the Delaware Valley.  The experienced professionals at David Anderson & Associates provide forensic accounting, business valuation, fraud investigation, fraud deterrence, litigation support, economic damage analysis, business consulting and outsourced CFO services.  Company principal David Anderson is a forensic accounting expert in Philadelphia who has more than 30 years of experience in financial and operational leadership positions and is a Certified Public Accountant, a Certified Fraud Examiner and a Certified Valuation Analyst.