Legally false claim

Question

Hospital committed multiple frauds, that created basis for further fraudulent assessment of patient's health. Apparent, but may be used as distracting factors in regard to non-existent terminal disease.  
After discharge from hospital patient was referred by unidentified hospital provider to hospice care with non-existent terminal disease recorded on admission to hospital. Hospital fraudulently charged medicare for 6 months. Does this situation present legally false claim? Specifically, with focus on hospice fraud?

Tim Akpinar · Answer

It's possible it could constitute a false claim, but for a more definitive opinion, it would be helpful for a medical professional/billing professional to review the records and coding applied. Good luck

James L. Arrasmith · Answer

Based on the information provided, there are several potential issues that could constitute false claims and healthcare fraud under California and federal law: 
 
1. If the hospital knowingly falsified the patient's diagnosis and health status in order to refer them to hospice care unnecessarily, this could be considered hospice fraud. Hospice fraud involves enrolling patients who are not terminally ill into hospice services and billing Medicare or Medicaid for those services. 
 
2. Fraudulently charging Medicare for 6 months of hospice care for a patient who did not have a terminal condition would likely violate the False Claims Act. The False Claims Act imposes liability on persons and companies who defraud governmental programs, including Medicare and Medicaid. 
 
3. If healthcare providers at the hospital deliberately falsified records or made misrepresentations about the patient's condition, this could potentially constitute healthcare fraud more broadly. Healthcare fraud includes a wide range of illegal practices, such as knowingly submitting false claims to Medicare or Medicaid, misrepresenting the type or level of services provided, or falsifying a patient's diagnosis to justify unnecessary medical services. 
 
Given the seriousness of the potential fraud issues you've described, I would strongly recommend consulting with a qualified healthcare law attorney who can review the specific facts of the case in detail. They can provide guidance on whether the hospital's actions meet the criteria for false claims, hospice fraud, or other legal violations under California and federal law, and advise on potential next steps.

Q: Legally false claim