Clinical labs play a very important role in provideing modern healthcare. However, some of the most significant cases filed under the False Claims Act have been related to clinical lab fraud.
Clinical lab fraud can take a number of forms including:
Laboratories may engage in illegal kickback schemes where they provide financial incentives or other inducements to physicians or healthcare providers in exchange for patient referrals. These kickbacks can lead to unnecessary tests being ordered or patients being directed to specific labs.
This occurs when a laboratory bills for individual tests that are typically bundled together and billed as a single panel. By billing separately for each test, the lab can inflate the overall reimbursement and increase revenue.
Upcoding involves billing for a more expensive or complex test than was actually performed. Laboratories may manipulate billing codes to receive higher reimbursements for services rendered.
False billing involves submitting claims for tests or services that were not provided at all. This can include billing for tests that were medically unnecessary or duplicative.
Improper Marketing and Sales Practices
Some labs engage in deceptive marketing practices to attract more business. This can include offering free or discounted services to patients or physicians, misrepresenting the accuracy or necessity of tests, or providing improper incentives to sales representatives.
Billing for Non-Covered Services
Laboratories may bill for tests or services that are not covered by insurance or government healthcare programs. This can include billing for experimental or investigational procedures or using improper codes to bypass coverage restrictions.
Prosecuting a claim under the False Claims Act is complex. Those who believe they are aware of pharmaceutical fraud should consult an experienced attorney to determine the steps necessary to protect themselves and file a successful claim.