Practice Areas

Hospital and Physician Fraud

Hospital and physician fraud involves billing Medicare or Medicaid for services that were not medically necessary, diagnoses that were not supported by the medical record, or inpatient admissions that did not meet the criteria for that level of care. If you work in a hospital, physician practice, or healthcare system and have witnessed any of these practices, you may have the basis for a qui tam case. Reach out for a confidential conversation. There is no obligation.

Practice Areas

Hospital and Physician Fraud

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WHAT IS HOSPITAL AND PHYSICIAN FRAUD?

Medicare and Medicaid reimburse hospitals and physicians for services based on what was actually provided, what was medically necessary, and at the level of care that was clinically appropriate. Hospital and physician fraud occurs when providers submit claims for services that were never performed, inflate the complexity or severity of a diagnosis to receive higher reimbursement, or bill for a level of care that exceeds what the patient’s condition required.

Because these claims are submitted to Medicare or Medicaid, they fall within the scope of the False Claims Act. Healthcare insiders who have direct, first-hand knowledge of systemic fraudulent billing practices within a hospital or physician practice may be eligible to file a qui tam lawsuit on behalf of the government and receive a share of any financial recovery.

In January 2026, the Department of Justice filed a False Claims Act complaint against Priority Hospital Group, a Louisiana-based hospital management company, alleging that it held patients longer than medically necessary in order to increase Medicare reimbursement, and that it paid remuneration to physicians to induce referrals in violation of the Anti-Kickback Statute and the Stark Law.

Source: U.S. Department of Justice, January 23, 2026 | justice.gov

Legal basis: 31 U.S.C. § 3729 (False Claims Act) | 42 U.S.C. § 1396 et seq. (Medicaid) | Source: uscode.house.gov

TYPES OF HOSPITAL AND PHYSICIAN FRAUD THIS PRACTICE HANDLES

Hospital and physician fraud encompasses a range of schemes. The following are the most common types handled by this practice.

Unnecessary Services: Billing Medicare or Medicaid for services, procedures, or treatments that were not medically necessary. This includes performing and billing for diagnostic tests, surgeries, or interventional procedures without a legitimate clinical indication, or ordering unnecessary services to generate additional revenue. Clinical staff, including nurses, technicians, and physicians, are often in the best position to recognize when services are being performed for billing purposes rather than patient need.

False Diagnoses: Submitting claims to Medicare or Medicaid supported by a diagnosis that was not documented in the patient’s medical record or was deliberately falsified to justify a service or procedure. This includes adding diagnosis codes that were not clinically present, overstating the severity of a condition, or documenting conditions that the patient does not have in order to make a claim appear medically necessary.

Upcoding Severity of Conditions: Assigning a more severe or complex diagnosis or procedure code than the patient’s actual condition or the service actually rendered would support, in order to receive a higher reimbursement from Medicare or Medicaid. Upcoding may affect evaluation and management services, inpatient admissions, surgical procedures, or any other billable service where the reimbursement rate depends on the complexity of the diagnosis or intervention.

Inpatient Admission Fraud: Admitting patients as inpatients and billing Medicare at the inpatient reimbursement rate when the patient’s condition only justified outpatient or observation status. Medicare reimburses inpatient admissions at a higher rate than outpatient services. Hospitals that systematically admit patients who do not meet the inpatient criteria, or that delay discharges beyond the point of medical necessity in order to increase per-diem reimbursement, may be submitting false claims to Medicare.

Legal basis: 31 U.S.C. § 3729(a)(1)(A) (false claims) | 31 U.S.C. § 3729(a)(1)(B) (false records or statements) | 42 U.S.C. § 1395 et seq. (Medicare) | Source: uscode.house.gov

WHO CAN REPORT HOSPITAL AND PHYSICIAN FRAUD?

The strongest hospital and physician fraud qui tam cases come from current or former employees who have direct, first-hand knowledge of the systemic fraudulent conduct from inside the organization. This includes nurses and clinical staff who know what services were and were not provided and whether they were medically necessary, billing specialists and medical coders who are instructed to assign codes that do not reflect the documented clinical encounter, compliance officers who have identified fraudulent billing patterns within the organization, physicians who have been pressured to order unnecessary services or document diagnoses that are not clinically supported, and hospital administrators or finance staff who are aware of billing practices that systematically misrepresent the level of care provided.

You do not need to have all the documentation before contacting us. If you have witnessed conduct that you believe constitutes systemic false billing to Medicare or Medicaid for hospital or physician services, that is enough to start a confidential conversation. We investigate thoroughly before asking for any commitment.

In fact, many former employees come forward with knowledge of fraudulent practices by their former employers after they have been demoted or terminated for complaining to their supervisors about the fraudulent practices or leaving their employment because they refuse to participate in the fraud.

Legal basis: 31 U.S.C. § 3730(b) (qui tam provisions) | Source: uscode.house.gov

YOUR PROTECTIONS AS A WHISTLEBLOWER

When you file a qui tam complaint, it is submitted under seal and served on the Department of Justice and any state agencies that have been impacted by the alleged fraud. Your employer is not notified and does not receive a copy of the complaint while the case is under seal. Your identity remains protected throughout the government’s investigation.

The False Claims Act prohibits your employer from firing, demoting, suspending, harassing, or otherwise retaliating against you for reporting fraud or participating in a qui tam case. These anti-retaliation protections apply to both current and former employees.

If your employer retaliates against you, you have legal remedies that include reinstatement, two times the amount of back pay owed, interest on that back pay, and compensation for special damages including litigation costs and attorney fees.

Legal basis: 31 U.S.C. § 3730(h) (anti-retaliation) | 31 U.S.C. § 3730(b) (under seal filing) | Source: uscode.house.gov

WHISTLEBLOWER REWARDS

When a qui tam lawsuit results in a financial recovery, the False Claims Act entitles the relator to receive a percentage of the total amount recovered by the government. If the government intervenes and takes over the case, the relator may receive between 15% and 25% of the recovery. If the government declines to intervene and the relator proceeds independently, the share can rise to between 25% and 30%. There is no cap on the dollar amount of the reward. We work on a contingency fee basis. There is no upfront cost, and if there is no recovery, you owe us nothing.

Legal basis: 31 U.S.C. § 3730(d)(1) and § 3730(d)(2) | Source: uscode.house.gov

About This Practice

Arvind Bob Khurana has over 27 years of experience in qui tam and False Claims Act litigation, complex commercial litigation, and class action matters. He began his career at a top international defense firm and joined a national class action firm in 2005, becoming partner in 2009, where he worked on ERISA actions, qui tam cases, securities fraud, and antitrust matters. He is admitted to the New York State Bar and represents whistleblowers in federal courts nationwide.

We are selective. Before we ask for any commitment, we investigate the claim, explain the facts and the risks, and give you a complete picture of what you are facing. We never ask you to sign a retainer agreement until you have the full picture and have decided, on your own terms, that you want to move forward. You remain in control throughout.

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Arvind Bob Khurana has over 27 years of experience in complex litigation. We work on contingency. There is no upfront cost and no obligation to proceed.