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What Are the Success Rates of False Claims Act Cases?

Find out why success rates of false claims act cases remain high.

Success Rates of False Claims Act CasesThe success rates of False Claims Act cases have been on the rise for the past decade. Unfortunately, as financial rewards grew, so did the number of nuisance cases. The government spends money whenever they investigate an FCA lawsuit, so eventually, the Department of Justice asked prosecutors to assess cases more diligently. Specifically, they chose to place emphasis on the right to file for dismissal of certain lawsuits to avoid unnecessary costs.

The goal of a memo released in January 2018 by Michael Granston, the director of the Commercial Civil Fraud Division of the DOJ, was to reduce government waste and conflicts associated with FCA litigation. Once public, the Granston Memo created the impression the government would not be as supportive of FCA cases as it had been in the recent past. The memo caused worry the lawsuits weren’t as likely to be successful. Thankfully, that isn’t how things have played out in practice.

Hundreds of Cases, a Handful of Dismissals

When a whistleblower files a lawsuit, government agencies assess the case to see if they should intervene. It’s beneficial when a government agency joins a case. It brings a tremendous number of resources to the table. Whistleblowers usually have the choice to continue the case on their own if the government refuses. There is one exception: 31 U.S. Code § 3730(c)(2)(A).

The law allows for the government to file for a dismissal of a case when it meets specific guidelines. Lawsuits have clarified when these requests are appropriate. Namely, they must pertain to:

  • Meritless or opportunistic qui tam cases
  • Lawsuits that would interfere with federal policies and procedures
  • Lawsuits that would interfere with existing cases initiated by the government

Over the year, as whistleblowers filed more than 700 qui tam lawsuits, the government sought to dismiss only a handful. Most recently, the government sought to dismiss 11 cases, all filed by the same plaintiff, which claimed preauthorization of prescriptions and patient education materials supplied by pharmaceutical companies amount to illegal kickbacks.

These are helpful resources which help patients enjoy a safer, higher quality of care, and federal regulations require them in some cases. It was right for the government to intervene. Not only did the decision save money, but it protected the rights and safety of patients and the efficiency of existing healthcare programs. It’s obvious the memo has not created a wave of dismissal requests as some feared.

However, finding a lawyer experienced in the type of FCA case you want to file is more important than ever. You’ll need to be able to follow the letter of the law, and each type of violation has its own specifics.

Success Rates for Qui Tam Cases Remain High

According to data tabulated by Taxpayers Against Fraud, approximately 80 percent of FCA cases are qui tam suits. The overwhelming majority result in monetary settlements, awards, or restrictions for companies.

In one of the first cases of the new year, the pharmacy giant, Walgreens, reached a historic agreement with the government in a prescription billing scheme reported by an employee. The whistleblower in that case will receive 21 percent of a record-breaking $60 million settlement.

Together, the lawsuits recovered over $3.7 billion in federal funds last year – the eighth year in a row where awards have capped $3 billion – and qui tam suits recovered more, on average, than those the government waged on its own. In 2017, cases where the government declined to intervene resulted in awards of $426 million.

Despite the Granston Memo, FCA cases remain one of the most effective means of fraud detection in government spending. That’s true in large part to qui tam provisions which reward individuals financially for filing suit. Since 1986, whistleblowers involved in qui tam suits have collected more than $6.5 billion.

That’s different from saying anyone who files a lawsuit is going to cash in. Before taking up a cause, it’s important to work with a lawyer who can accurately assess your chances of winning and research whether or not the government will have cause to try to dismiss your case.

What Do We Need for the Laws to Change?

President Lincoln passed the FCA with the help of Congress in the 1800s. Fraudsters took advantage of Civil War funding without delivering on their promises. As a result, soldiers starved and froze to death without adequate supplies. The war was long, and the lack of reliable supplies led to significant losses on both sides. Legislators couldn’t ignore it.

In the 1940s, Congress revisited the FCA, making changes to the law which severely limited the benefits and benefits it would provide. Corruption soared again until, in the 1980s, Congress dealt with massive misspending within the Department of Defense.

These days, it’s used mostly to protect people against healthcare fraud. Legislators know these cases aren’t just saving money. They’re saving lives. It’s doubtful they’ll limit the reach of the FCA anytime soon. However, there are higher expectations placed on lawyers who try these cases.

Finding the right person for the job is more important to your success than ever. You’ll find the team you need by contacting the skilled FCA case attorneys at Bothwell Law Group by clicking or calling 770.643.1606 today.

What Are the Required Skills of a Medicare Qui Tam Attorney?

Discover the top traits of an experienced Medicare qui tam attorney.

Medicare Qui Tam AttorneySelecting the right Medicare qui tam attorney is more important than ever before. Over the past ten years, the number of qui tam cases has increased. Nuisance cases have the potential to cost the government a fortune. Preventions are in place, but you have to be careful they don’t interfere with your ability to file a case.

In 2018, the director of the Commercial Civil Fraud Division of the Department of Justice released a memo encouraging government lawyers to do a more stringent job of evaluating cases. More than that, it encouraged prosecutors to file motions to dismiss cases in certain situations to avoid contradictions in law and government waste. Over the past year, they’ve ramped up the number of dismissed cases, but often for a good reason.

For example, the government recently filed to dismiss 11 cases across seven federal districts, all raised by the same firm. The motion specifically called the lawsuits “meritless” and pointed out the case encroaches on policies put into place by federally mandated health programs.

The lawsuits’ main complaint? Pre-authorizations for prescriptions and providing patients with the education needed to use medications correctly are incentives in violation of the Anti-Kickback Statute.

It looks like the firm was using technicalities in the hopes of securing a payoff, and the government rightly put a stop to it. Is any part of their case valid? We’ll never know. It’s possible they’re working to stop a real problem that wasn’t clear in the filing. Working with the right lawyer ensures your case will stay active and get the support it deserves.

How do you know which lawyer is qualified? Keep an eye out for these traits and skills:

They’re Professional

When researching lawyers, make sure you’re looking at real lawyers and not someone who is misrepresenting himself to get your contact information. Referral services can look convincing, and their platforms make it easy to get the details of your case.

You also have to keep a lookout for a different kind of fake. Whenever you’re raising a qui tam suit, you have to file your claim appropriately to have whistleblower protections — and rewards. Pass your information to the wrong person, and they can attempt to raise the claim first. They could also contact the intended defendants to help them get a leg up.

It helps to check with the state bar association in your lawyer’s area to ensure they’re a true professional.

They’re Experienced

Winning lawyers aren’t experts in every area, and Medicare qui tam suits have very specific guidelines to follow. While you might not be able to stay anonymous, there are certain things you can do to protect yourself if you come forward. For instance, your employer cannot do any of the following if you have filed a whistleblower case:

  • Fire you
  • Demote you
  • Fail to advance you
  • Harass or threaten you

In some instances, an experienced attorney can help you preserve your anonymity or take extra measures against retaliation.

Most importantly, when included in a qui tam lawsuit, you’re eligible to receive a portion of any settlement or lawsuit winnings. Successful whistleblowers have received millions of dollars. There’s a lot at stake, so you want to work with someone you know will get things right.

They’re Well Connected

With the crackdown on frivolous qui tam lawsuits, who you know might become more critical over time. While the DOJ acknowledges how important cases are in keeping corruption at bay, the number of cases filed has reached a tipping point where the potential costs involved in intervention might outweigh the benefits of catching certain crimes.

Government intervention helps improve your chances for success, so hire someone who has worked alongside government agencies in the past. Bring in a lawyer with a reputation for filing and winning valid cases. It can help convince an agency your lawsuit is worth the investment.

They’re Ready for a Fight

Filing Medicare qui tam lawsuits don’t typically require a considerable cash investment up front from the client. Instead, the lawyers take their fees from the case winnings. Others charge per hour or per motion. It’s essential you understand billing procedures before you sign on with a legal professional. Will your lawyer be able to invest the time and money into preparing your case?

With so many considerations to make when choosing a lawyer, it pays to do your research. Every minute spent on research goes toward a winning settlement. Learn more about finding the right Medicare qui tam attorney by contacting Bothwell Law Group online.

How the Qui Tam Act Rewards People Who Come Forward

Wonder how the qui tam act rewards whistleblowing? Your bank account wants to know.

Qui Tam Act RewardsThe qui tam act refers to provisions of the False Claims Act (FCA) that make it possible for individuals to sue corrupt companies on behalf of the U.S. government. Cases must meet specific requirements to go forward, but successful wins result in big rewards. According to the Department of Justice, qui tam rewards going to filers topped $393 million in 2017. These cases are the government’s best weapon against fraud in government spending.

If you’re reading up on qui tam lawsuits, you’re probably worried about a situation at work. While laws are in place to protect you from retaliation, it can still be enough of a concern to keep people from speaking out. Sharing in the financial awards or settlements of FCA cases helps lessen the burden whistleblowers bear. It also acts as encouragement for others who see a problem to report it to the authorities.

Qui Tam Rewards in the Millions

Successful qui tam litigants often walk away from the courtroom with serious cash. How? The FCA gives individuals the right to share in financial settlements and awards from cases they initiate. In 2017, FCA lawsuits recovered more than $3.7 billion of taxpayer dollars. Relators, individuals who initiate the suits, can take home up to 30 percent of the winnings.

In a recent record-breaking win against Walgreens, for instance, the courts awarded 21 percent of the $60 million settlement to the whistleblower. The case highlighted a prescription billing scheme by which the pharmacy chain bilked federal and state healthcare programs out of millions of dollars by inflating the costs of prescription drugs.

That said, cases can last a long time. It’s not unheard of for a lawsuit to take years. There’s no guarantee the government will help your case, however. In fact, the U.S. government can not only refuse to assist, but it can also request the courts dismiss your case.

You can still forge ahead on your own and be successful. In 2017, cases where the government chose not to intervene brought in $425.7 million, and relators took home $43.6 million of the proceeds. It’s easier when the government gets involved — and much easier when they don’t try to fight your case!

There’s more than money involved in these fraud cases though. Individuals don’t raise an FCA lawsuit for a simple cash grab. You can see the real benefits the FCA in its origins.

Qui Tam Cases Help You Make the World a Better Place

The FCA is sometimes referred to as Lincoln’s Law. Out 16th president signed it into law in 1863. Congress passed the act in response to Civil War-related fraud against the government. Unscrupulous vendors promised to give our troops warm, durable clothes, sturdy shoes, and healthy meals, but they rarely delivered.

Similarly, today’s worst offenders aren’t just taking the money they don’t deserve. They’re hurting people in the process. In some cases, they’re killing them. Three examples from recent years truly demonstrate the consequences faced by victims of government fraud.

In the first, a company called Second Chance Body Armor was selling defective bullet-proof vests to law enforcement agencies across the country. The ruling determined their guilt and the federal government reimbursed the law enforcement groups for the purchased vests. For years Second Armor knew their products weren’t safe but continued to mislead agencies. Eventually, the scam led to the death of a police officer killed when a bullet went through his protective gear.

In another case, a dental management company settled for $23.9 million for their role in a Medicaid scheme in which dentists performed unnecessary root canals on baby teeth. Parents who rely on Medicaid can’t often afford to get a second opinion. The result? Thousands of children went through the pain and risk of dental surgery without any reason.

The largest Medicare fraud case of the century involved a group of 30 retirement homes throughout Florida. The owner paid hospital workers to refer thousands of patients who did not need in-patient care. He subjected patients to unnecessary procedures and used narcotics to keep them from speaking. Authorities say he fraudulently billed Medicare over $1 billion for their care. Not only did he abuse thousands of elderly people, by robbing Medicare he prevented others from getting the help they needed.

It took employees working with those companies to come forward to keep people safe. The financial rewards were fringe benefits. The payoffs involved in being a whistleblower often focus on the financial, but in reality, the results can go far beyond the bank account. Finding the right lawyer can help you maximize the results.

Find out more about the qui tam act and all of its benefits by contacting Bothwell Law Group online.

What a Pharma Whistleblower Attorney Does in Whistleblower Cases

pharma whistleblower attorney

What to look for in the right pharma whistleblower attorney.

Choosing a pharma whistleblower attorney is one of the most important steps in winning your case. You want someone with a thorough understanding of qui tam case law in practice, not just in theory. Hiring a family friend or a lawyer based on convenience could come back to bite you. Be sure to pick someone with the essentials necessary to win in a pharma case.

Your lawyer needs the knowledge, skills, and resources to:

  • File your case correctly
  • Navigate common roadblocks
  • Perform appropriate research

Look at former cases to get an idea of what your lawyer might have to handle. For instance, in 2013, DaVita Medical Holdings LLC succeeded in having the FCA case against their company dismissed. The whistleblower in the case, James Swoben, filed an appeal and eventually the company settled for $270 million. Swoben received over $10 million from the agreement but had to fight for compensation of an earlier $322 million settlement by another company involved in the case.  

In another instance, whistleblower Stephanie Schweizer sued her employer for retaliatory conduct. She went on to sue the government when they accepted an extraordinarily small settlement in the case.

False Claims Act (FCA) cases against big pharma are too tricky to go into ill-prepared. Here are just a few ways to know you’re ready for battle.

Make Sure the Lawyer Is Really a Lawyer

While impersonating an attorney is a crime, some professional referral agencies go out of their way to blur the lines. They provide an abundant amount of information on specialized representation in the hopes of referring your case to a lawyer and getting a fee in return. It can be difficult to spot these sites, especially if you’re upset or nervous.

Often they don’t list attorneys by name on their websites. Some list employees and allow visitors to assume they’re law professionals when they’re really “account executives.” Worst case scenario? These people could be fronts for industry leaders looking to stay ahead of their own legal problems. Before giving lawyers the details of your case, check out their credentials with the state bar association.

Look for People Familiar with Pharma-Specific Whistleblower Cases

Corruption is rampant throughout every level of our economy. From education to stock trading, companies are fudging the books and purposefully making bad deals at the expense of their clients. Unfortunately, the rules in each of these industries are unique. The methods for exposing fraud are specific to each situation. Handling things the wrong way will destroy your case and potentially put you at risk. So, it’s essential you work with a lawyer who has experience with cases involved in pharma whistleblowing.

That means asking for a list of cases they’ve worked on and what work they performed. It also means investigating each case to make sure the lawyer is representing the information honestly and accurately. Lawyers are like people in any other profession. Sometimes they exaggerate to land the right client. Double-check their facts to make sure they’re telling you the truth.

  • Did the client or case run into any problems?
  • Was the case successful?
  • Did the government intervene?

Ideally, the lawyer you choose to work with will have experience leading a pharma whistleblower case, from filing the initial paperwork to securing a win for the client.

Ask About Working Alongside the Government

When you sue on behalf of the U.S. government, the appropriate agency reviews the case and decides whether or not to join you in the case. It’s fantastic when they do. The number of resources they bring to the table and the means they have for discovery almost ensure a win.

Unfortunately, the government is cracking down on whistleblower lawsuits and calling for more stringent assessment before the intervention. With the rise in suits over the past five years, costs are also on the rise. Has your lawyer convinced the government to hop on board in the past? If not, you might want to work with someone else.

Double-Check the Traditional Costs of Doing Business

Sometimes whistleblowers choose lawyers based on the lawyers’ location relative to their own because they don’t have the funds needed to get back and forth. This is short-sighted and solves a problem that might not exist. Whistleblower attorneys are often prepared to handle communicating with someone long-distance. Before you limit your choices based on location, be sure to ask if it’s necessary.

Investigating the above issues will provide you with the basics you need to know whether your lawyer is a qualified one. When you’re ready to connect with a skilled pharma whistleblower attorney, talk to the team at Bothwell Law Group by clicking or calling 770.643.1606 today.

Understanding the Basics of Whistleblower Legislation

What are the basics of whistleblower legislation, and how does it relate to you?

Basics of Whistleblower LegislationWhistleblower legislation isn’t a modern invention. It arose from corruption in the 19th Century, particularly as predatory companies scrambled to take advantage of government expenditures made during the Civil War. Fighters on both sides of the conflict were at a loss for essential supplies, from boots and jackets to edible food.

Companies contracted to provide the goods failed to deliver or dispensed products of such poor quality they were worthless. Widespread fraud directly contributed to deaths on the battlefield.

Establishing the ‘Lincoln Law’

President Abraham Lincoln is famous for many things, but one of his lasting achievements was the passage of the False Claims Act (FCA). Sometimes called the “Lincoln Law” in his honor, the act gives individuals the right to sue other people, businesses and organizations on behalf of the United States when they are guilty of defrauding government programs. Not only does it stop the crime from happening, it also gives the individual a chance to share in settlement or judgment payments.

Litigation doesn’t stop there. It’s important for fraud reporters to know criminal charges often accompany these lawsuits. A recent example is the owner of Texas-based Houston Healthcare Clinics, found guilty of Medicare fraud. The FCA case resulted in fines of $2.7 million and a 36-month prison sentence.  

The FCA has played a central role in breaking up corruption in all major industries. Inappropriate military spending was a hot topic in the 1880s and again in the 1980s. In previous decades, financial mismanagement was all the rage. Today? Whistleblowers are using the False Claims Act to force changes in the healthcare industry and stop companies from taking advantage of our most vulnerable populations.

How Is Fraud Uncovered?

One of the reasons Medicare fraud is on the rise is because of how easy it is to get away with it. Many times, patients are in no position to go over their insurance statements. Complicated rules regarding medical coding also make it difficult for a patient to know whether they’re billed correctly.

Many of the whistleblowers filing suit under the FCA are employees of companies committing fraud or their partners. A clinical social worker who noticed an ambulance company was providing transportation for patients at a premium sued the company and collected roughly $160,000 from the settlement. She helped her finances, but more importantly, she stopped the company from taking advantage of her patients and the Medicare program.

In other cases, secondary victims uncover the problem and speak out. In Florida, former medical director and whistleblower Dr. John Simons discovered his signature on paperwork he didn’t sign. Also from Florida, Dr. Donna Bell discovered a medical supply company was using her credentials to forge prescriptions for medical equipment to patients who weren’t in her care.

Rarely do victims have the knowledge or know-how to fight fraud impacting their bank accounts and their quality of life. It is up to people in the industry to keep businesses honest.

Why Is the Fair Claims Act So Effective?

The Fair Claims Act offers whistleblowers the best of both worlds. On one hand, you’re able to guide the hand of justice and reap the rewards. Some fraud reporters receive tens of millions of dollars for their role in stopping government-related fraud.

In May 2018, the U.S. Securities and Exchange Commission awarded three whistleblowers a combined total of $83 million. That’s larger than most lottery winnings. But it didn’t happen by accident. The law rewarded the individuals for tipping off the SEC about fund mismanagement at Merrill Lynch.

The promise of financial reward is essential to convincing some people to come forward. Why? Because of the risks involved in outing crime.

The federal and state governments have laws to protect whistleblowers from harassment, demotion, dismissal, blacklisting and other forms of retaliation. Sometimes these laws only apply to public workers. In few areas do they extend to all employees. In False Claims cases, you might have fewer options.

Looking for Legal Protection?

It’s helpful to work with a competent legal team who understands whistleblower protections. How you report on problems makes all the difference.

A court dismissed the case of Kathy Reitzel, former finance director for the Keys School District in Florida. In 2009, the school board forced Reitzel to retire early after she outed the district’s director of adult education for embezzlement. Monique Acevedo, the wife of then-superintendent Randy Acevedo, racked up over $400,000 in personal charges on the school’s accounts.

Unfortunately, Reitzel had knowledge of the embezzlement in 2007. She went to the superintendent to deal with the matter privately. If she’d gone through the proper channels, the school board said, Reitzel would have saved the district a significant amount of money — and her job.

Having guidance when navigating whistleblower laws will ensure you stop wrongdoings without putting yourself at excessive risk.

Contact the experienced whistleblower legislation attorneys at Bothwell Law Group by clicking or calling 770.643.1606 today.

What You Need to Know about Different States’ Whistleblower Laws Before Coming Forward

How do different states’ whistleblower laws differ from federal protection?

state whistleblower lawsStates’ whistleblower laws provide added protection for people, but they also come with their own set of eligibility requirements. Assumptions can spoil your case before it even begins. Working with a lawyer can help you navigate the complaint process the appropriate way to ensure you’re covered by whistleblower protections. You might also be able to share in any judgments or settlements arising from your complaint.

Which States Have Whistleblower Protection Laws?

The federal government has a few different laws protecting employees who come forward about bad practices in the world place. In some instance, these complaints fall under the False Claims Act. If the inappropriate behavior involves defrauding the government, the person reporting the fraud can file a lawsuit on behalf of the nation. Once the case is over, the reporter is eligible to up to 30 percent of judgment or settlement fees.

Other federal laws protect the rights of public employees. Generally, these laws prevent demotion, firing, industry blacklisting, unreasonable work changes, and harassment. The same is true for laws in certain states.

The following states do not have whistleblower protection laws:

  • Arkansas
  • Georgia
  • Idaho
  • Maryland
  • Mississippi
  • Montana
  • Nevada
  • New Mexico
  • North Carolina
  • South Dakota
  • Texas
  • Vermont
  • Virginia
  • Wisconsin
  • Wyoming

Some states extend whistleblower protection to public employees. Others, like California, extend those rights to everyone. However, in states without whistleblower protections, professional associations and company policies often provide them.

However, in order to be eligible for protection under laws or policies, complaints have to follow proper procedures.

What Benefits Are Available to Whistleblowers?

There are different types of whistleblower complaints, but the two most common are:

  • Employees turning in a business for illegal or unethical behavior, and
  • Individuals turning in a person or business for government-related fraud

Whistleblower protection for employees prevents on-the-job harassment, industry blacklisting, firing or demotion, and the assignment of unreasonable transfers or changes in duties. In some cases, whistleblowers are able to stay anonymous.

Take, for instance, the case of 15-year hospital staffer Donna D. Ladka, of White River Junction, New Hampshire. After complaining about a doctor’s inappropriate sexual behavior, the doctor stopped speaking with her and the hospital relegated Ladka to paperwork duties. Gifford Medical Center later fired Ladka, citing supposed patient privacy violations. The hospital opted to settle with Ladka out of court, and the doctor involved had to undergo ethics training.

When it comes to fraud cases, whistleblowers enjoy additional benefits. The False Claims Act gives people the right to sue on behalf of the U.S. government. If the case is successful and results in a judgment or settlement, the whistleblower receives up to a third of the payment.

People can opt out of both protections and financial benefits in the blink of an eye simply by complaining in the wrong way. It’s important to understand the state and federal laws relevant to your situation so you don’t give away your rights.

Even then, there are situations which might leave you at risk.

Whistleblowers Who Left Themselves Vulnerable

Employer concerns over employee social media posts have grown steadily with the rise of sites like Twitter and Facebook. So many people were being fired – and contesting – over criticisms of their companies, the National Labor Relations Board addressed the topic specifically.

While encouraging employers to judge instances on a case by case basis, the NLRB supported firings, demotions, and similar consequences when an employee shares damaging personal opinions online. If you’re posting a complaint held by a group of employees? You could be in the clear.

Unfortunately, by venting online you might be giving up other important rights. For instance, a government agency who sees your post could sue your company based on those complaints before you get the chance. Therefore, if they’re found guilty of defrauding the government, you wouldn’t have a claim to any portion of the judgment.

Social media is a wonderful way for consumers to make changes in the way their favorite companies do business. However, employees should stick with official procedures for logging complaints. Sometimes, these missteps are surprising.

Barbara Gonzales, former financial director for Killeen, Texas, found out how hard it can be to register your complaint to the proper authorities. In Texas, whistleblower protections extend only to employees who notify a police officer of crimes committed in the workplace. City and company policies often fail to acknowledge this process, encouraging people to file complaints in alternative ways that will leave them vulnerable.

Finally, while protections are available at the state and federal level, whistleblowers need help navigating the legal waters when it comes to stopping fraud and other crime. Click to find out more about state whistleblower laws by contacting Bothwell Law Group online.

How to Protect Yourself as a Medicare Whistleblower

Is it dangerous to be a Medicare whistleblower?

medicare whistleblowerThe benefits of being a Medicare whistleblower are tempting, but do they outweigh the risks? Most people want to do the right thing, but when they are under pressure to provide information, office staff, healthcare providers, doctors and others caught up in fraudulent schemes sometimes say they were afraid to speak out. For others, the lure of securing a major payout is their major motivation. Find out how to make a complaint to enjoy the most protection.

Medicare Fraud Does Not Happen by Accident

The Association of American Physicians and Surgeons recently did a survey of their members on the topic of Medicare fraud. What they found was shocking. Over 80 percent of doctors fear an investigation. The majority weren’t defrauding anyone. They’ve just bought into the idea that complicated billing codes are the root of recent fraud cases — and the sizeable financial ramifications.

Nearly a quarter of practices no longer accept Medicare patients for the same reason. They don’t want to deal with the risks. A look at actual cases involved Medicare fraud show these fears are unnecessary. Medicare fraud doesn’t happen by accident.

Take, for instance, the case of Williston Rescue Squad, Inc., in South Carolina. The ambulance service had a year’s long history of transporting patients by ambulance when it wasn’t necessary and falsifying documents to meet Medicare transfer requirements. Finally, a clinical social worker who worked at a local hospital turned in the business.

Remember, Medicare rarely pays all your medical bills. So as the government was being defrauded, so were the patients!  The company replaced three top executives and agreed to pay the government $800,000. Because the social worker raised the complaint by suing the company in a qui tam lawsuit, she received $160,000 of the settlement. The False Claims Act has revolutionized many industries by motivating change from within organizations. The protections involved are as important as the potential benefits, but they aren’t always what they appear.

Surprisingly, the lawsuit listed the name of the whistleblower and her association with the Williston Rescue. The company, her employer and the general public knew she spoke out. Her name is Sandra McKee. She still lives in Augusta, Georgia, and still works for U.S. Renal Care, Inc.

Protection for Whistleblowers Depend on How You Complain

Whistleblowing does not always guarantee your anonymity, though working with an experienced legal team can help safeguard your privacy. There are many ways to legally protect yourself from the backlash. For instance, federal law prevents:

  • Firing
  • Demoting
  • Harassment
  • Industry blacklisting
  • Unreasonable transfers

A common, new trend is employees getting into trouble for venting their concerns over social media. While these individuals believe they are doing the right thing, this doesn’t constitute “whistleblowing.” By airing grievances in the public eye, you open yourself up to ramifications at work, as well as potential legal problems. Your employer could fire you and sue for defamation. Courts are finding in favor of businesses in these situations. Employees fired for public complaints have also gone without unemployment.

That said, most employers cannot fire you for complaining directly to management. One whistleblower who remained anonymous not only successfully sued her employer for firing her in retaliation for complaints, she went on to sue the government for accepting too small of a settlement. And she won.

False Claims Cases Are Not Get-Rich-Quick Schemes

Consider the case of James Swoben, a former employee of a Medicare Advantage Organization doing business with DaVita Medical Holdings LLC. Swoben alleged the Medical Services Organization instructed their healthcare providers to use the wrong coding information to receive higher rates of reimbursement.

DaVita settled in October for $270 million, of which, Swoben received just over $10 million. However, he first filed the case and saw it dismissed in 2013. An appeal in 2016 revived the case. In addition, one of the original defendants – SCAN Health – settled early on by paying $322 million. Swoben didn’t receive any portion of that payment and had to fight for his right to compensation.

There have been so many qui tam lawsuits raised in the last three years, some courts are raising the stakes for what constitutes fraud. Others are limiting the scope of “retaliation.” One former employee found this out the hard way when she sued based on anti-retaliation protection after she resigned.

Handled differently, the employee could have been a source for positive change while benefiting financially. Finding the right lawyer to walk you through the process makes all the difference.

Click to find out more about Medicare whistleblower protection by contacting Bothwell Law Group online.

Why Medicare Billing Fraud Cases Are Running Rampant and What You Can Do About It

medicare billing fraud

Are Medicare billing fraud cases getting worse? Here’s what you need to know.

Medicare billing fraud cases cost the government $60 billion a year, and the problem continues to grow. Abuse is rampant despite more restrictions on healthcare for seniors than ever before. As more doctors hear about fraud convictions and million-dollar fines, more providers are refusing to provide services to patients on Medicare. Some even refuse referrals. This is just one way Medicare fraud impacts people in real ways and why we need to put a stop to it.

Why Medicare Billing Fraud Cases Are So Common

There are several reasons billing fraud is on the rise. Some doctors say it’s easy to make billing errors given the complicated medical coding currently in use. Most fraud is really an accident. It seems like a reasonable explanation. Unfortunately, it doesn’t really address the most common fraudulent charges cropping up in today’s investigations.

There are clinics, care facilities, home-based healthcare workers, and others that aren’t just charging people for the wrong services. They’re charging for services never rendered for patients they haven’t seen. They’re splitting visits up and claiming each step in treatment occurred on a different day. That gives the office the ability to add additional office or exam fees. In some cases, doctors are charging patients who simply don’t exist.

Treatments Can Trigger Investigations

Unfortunately, it’s impacting what legitimate healthcare providers are doing. According to the Association of American Physicians and Surgeons, 71 percent of doctors restricted the services they offer. That’s because they’re afraid of triggering investigations. Another 23 percent won’t take on new Medicare patients at all.

Many times, it’s not the doctors or the facilities who are perpetrating the fraud. The latest wave of Medicaid billing deceptions come by way of shady medical supply companies who steal doctor’s licensing information and use it to forge subscriptions for expensive medical devices.

Hospice Isn’t Safe, Either

Another hotbed of fraudulent billing activity occurs in the growing hospice industry. Payments made for end-of-life care increased by 81 percent over the last decade. In 2016, it accounted for $16.7 billion of Medicare payouts. Officials estimate 10 percent of those payments were illegal disbursements. Scam artists have made a new industry of Medicare fraud, starting with the patients and families who are the most vulnerable.

The National Hospice and Palliative Care Organization blames extraordinary hurdles in coding for the fact so many hospice organizations are mistakenly bilking the system. The most common issue? Centers charging patients for “general inpatient care” when they receive their services in their homes. The difference is not only obvious, but it results in a reimbursement difference of over $500 per day.

It’s heartbreaking to know that even with rampant billing fraud within the Hospice community, patients overwhelming receive substandard care. A review by the Inspector General at the Department of Health and Human Services (HHS) found 85 percent of patients were not receiving the level of medical care determined necessary by their treatment plans.

The reason Medicare fraud is growing is simply that the system makes it so easy. Patients don’t see their bills before they before the insurance company pays for services. Confusing medical billing impacts whether they’re able to assess what the statements mean once they arrive. And for those in inpatient programs, reporting Medicare fraud can come at an exceedingly high price.

Putting a Stop to Medicare Fraud

Who can help stop medical billing fraud?

  • Patients
  • Family members
  • Healthcare workers
  • Office staff

Patients and their family members need to be diligent when reviewing Medicare statements in order to detect any errors. When discovered, contact the healthcare provider and ask for a correction. If you’re treated poorly or given the run-around, it might be time to take extra steps to protect your loved one’s benefits.

Healthcare workers and office staff can also help prevent fraud from hurting their patients. Remember, some services have limited coverage. If someone is incorrectly billed for a service or a piece of medical equipment, they won’t receive that coverage again. Speaking up preserves your ability to give patients the care they need and preserves your ability to earn an income.

How Qui Tam Lawsuits Stop Fraud and Boost Your Bank Account

Under U.S. law, any person can sue a business or individual who is defrauding the government. You represent the nation and share a portion of the reward or settlement. Whistleblowers calling out Medicare fraud received millions of dollars, and they’ve helped stop companies from preying on the sick and elderly.

There’s a certain way you have to make the complaint in order to be eligible to receive any funds, so make sure you take your concerns to a lawyer who is familiar with Medicare fraud litigation.

Contact the skilled Medicare billing fraud attorneys at Bothwell Law Group by clicking or calling 770.643.1606 today.

Is Workplace Whistleblowing Effective in Educational Settings?

When it comes to education, workplace whistleblowing might seem like a more significant risk than it is.

Workplace WhistleblowingIs workplace whistleblowing really protected when it comes to education? The way some administrators run their schools and districts would make you wonder. Just asking for small changes or money for simple repairs can put you on the naughty list. It can be hard to believe that making an official complaint would lead to anything but problems, but there are laws to protect you from facing retaliation. In some cases, it’s possible to make a complaint while staying completely anonymous.

Part of the Problem or Part of the Solution?

Being part of a team is central to educational institutions and a team spirit is key to their success. Every teacher, every aide, every tutor or janitor in place plays a role in motivating students to perform their best. It’s normal for administrators to put in 110 percent and to expect the same from their employees.

Working as part of something larger than yourself is a rewarding experience, but what happens when problems arise? There will always be some people who see any criticism as an attack. Others will always feel strongly you should keep complaints to yourself or handle them privately. Turning in a complaint might come across as disloyalty, and suddenly, you’re not dealing with a problem anymore. You’re in a situation where it is you vs. them. If you “snitch,” you become the enemy.

This destructive cycle affects schools throughout the U.S. and has contributed to significant abuses regarding the handling of funds and of students. It’s imperative for people to feel safe coming forward about problems to ensure our kids stay safe. Unfortunately, the community culture among most school staff works against filing complaints.

Avoiding an “Us vs. Them” Situation

In theory, there are laws in place to protect whistleblowers; however, regarding education, strict guidelines are dictating how and to whom they should make the complaints. A lawyer can walk you through the specifics of your situation, though the Department of Education covers the basic framework here.

Government employees have different protections and responsibilities than those who are working for contractors, or perhaps, just applying for jobs.

The law can prevent you from being:

  • Fired
  • Demoted
  • Transferred
  • Harassed
  • Or threatened

Among other things, for filing a complaint, the law can’t force your coworkers to continue to trust you or be friendly. Hiring a lawyer before filing a complaint can sometimes help you preserve your anonymity.

The Difference Workplace Whistleblowing Makes on Student Quality of Life

For obvious reasons, it’s difficult for whistleblowers in education to come forward, but the benefits often outweigh the risks. When institutions misuse and abuse their positions, they have a direct and negative impact on the lives of students.

For instance, whistleblowers in education have been responsible for stopping:

  • Physical and sexual abuse
  • Failure to provide adequate special education
  • Mismanagement of school funds

Unfortunately, too many people assume they have protections they don’t have when sharing information. According to the Department of Education, there are only certain people to whom you can complain to for whistleblower laws to count.  

Former Illinois principal Julie McArdle found this out the hard way when raising concerns about questionable spending of her predecessor-turned-superior. Not only was McArdle fired, but the court found in the school boards favor, saying First Amendment protection doesn’t apply when you’re speaking on behalf of a government employer. She hadn’t made the complaint to the appropriate person, so it wasn’t covered under whistleblower laws or as freedom of speech.

Things are turning out differently for a part-time nurse for the Park City School District in Utah. After facing harassment, hostility, and termination following her official complaints regarding a lack of services for diabetic students, Nicole Kennedy sued the district and select administrators for violating whistleblower laws. Summit County 3rd District Court Judge Richard Mrazik refused to dismiss the lawsuit last month. The case is currently in mediation.

Education Fraud and Qui Tam Lawsuits

The False Claims Act allows individuals to bring qui tam lawsuits against those who engage in government-related fraud on behalf of the nation. These cases allow whistleblowers to share in judgments. Billions of dollars go to whistleblowers every year. However, it’s essential to file claims in the right way to be eligible to take part.

Fraud cases from the last year include:

  • Individuals filling out federal loan applications for students without their knowledge
  • Event planners scamming schools out of money for services they never intended to provide
  • Tutoring companies billing the government for services they did not offer
  • Charter schools using deceptive strategies to avoid paying taxes

What’s unique in these situations is that companies faced fines but individuals also went to jail—in some cases, for ten years or more.

We know how difficult it is to stand up and do the right thing. Having the proper legal representation makes whistleblowing simpler and safer.

Contact the skilled workplace whistleblowing attorneys at Bothwell Law Group by calling 770.643.1606 today or connecting with us online.

How a Lawyer for Whistleblowers Works

How does a lawyer for whistleblowers help and protect you? We’ll show you how to fight back and stay safe.

Lawyer for WhistleblowersUnder the law, a lawyer for whistleblowers is meant to ensure people feel safe coming forward when bad people are doing bad things. In certain situations, you can file complaints anonymously to help prevent retaliation. In others, you may be able to benefit financially from uncovering fraud and other wrongdoings.

Generally speaking, laws protect whistleblowers from the following:

  • Threats or harassment
  • Demotion or termination
  • Industry blacklisting
  • Failure to promote
  • Prosecution

Your employer’s policies will have the most significant impact on the responses you should expect for filing a complaint with the company or against the company through an outside agency. Your HR department should have an updated employee handbook, a document you should be able to request without raising any red flags.

The protections provided through U.S. and state law depend primarily on your situation. Who is your employer? What are you reporting? Every whistleblower doesn’t have the same protection.

Understanding the Whistleblower Protection Act

The Whistleblower Protection Act of 1989 (WPA) and the Whistleblower Protection Enhancement Act of 2012 provide federal employees with the right to disclose information on wrongdoing. Other federal and state laws encourage reporting of wrongdoing while offering measures to keep informants safe.

In certain situations, enforcing privacy rules is essential to protecting whistleblowers. For instance, laws prevent the Securities and Exchange Commission from revealing the identity of informants or information that could lead to their identification. People’s lives are in danger when millions of dollars are at stake. A lawyer can help you limit your risks of exposure.

Unfortunately, the courts responsible for claims sometimes restrict the way they interpret the laws, placing whistleblowers at risk. If you have to expose classified information, for example, it’s important to discuss the ramifications with a legal consultant. Espionage charges are no laughing matter. It’s essential to protect the public. But laws are in place to make that possible while avoiding jail or other negative repercussions.

Protected Actions and Liabilities

It’s important to distinguish between whistleblowing activities and other actions an employee takes. Whistleblowing will not protect you from the consequences of your behavior. Mark Whitacre is a good example.

As an executive for an agricultural corporation, Archer Daniels Midland, Whitacre outed the company for price-fixing while at the same time embezzling more than $9 million. Being a whistleblower didn’t stop him from going to jail for his crimes.  

Likewise, if you engage in behavior that breaks codes of conduct at your employment in the wake of a complaint, you might face termination, demotion and other repercussions. The business just can’t target you unfairly because you brought problems to light.

Whistleblowers and the False Claims Act

Some of the laws not only provide protection from harm but offer incentives for exposing illegal activities. The False Claims Act (FCA) affords individuals the right to file qui tam lawsuits, meaning they can sue others on behalf of the United States government. If a court decides the defendant is guilty of defrauding the government, the whistleblower receives 15 – 30 percent of the judgment. The law has successfully reduced corruption in a number of industries.

These days, courts wield the FCA to stop Medicaid and Medicare fraud, but it’s useful in other applications as well. Last year, the law helped reclaim more than $3 billion in government funds.

In one case, when a senior control analyst for medical device-manufacturer Alere came forward regarding the product’s unreliability, she received $5.4 million as part of a settlement agreement.

Mylan Inc., the manufacturer of the EpiPen, came under fire for raising their products price by over 400 percent. At the same time, the company was misclassifying the product as a generic to qualify for a lower 13 percent Medicaid rebate rate. The $465 million went back into federal and state healthcare programs.

Billing Complications

Unfortunately, the U.S. Department of Justice might have become too critical of billing policies in recent years. In November 2017, a court overturned a landmark billion-dollar judgment against rehabilitation center HCRManor after the company’s legal team successfully argued against the DOJ’s discover methods and star witness.

It’s important to discuss your risks and obligations in situations where you file a case but wind up losing in the end. You also want to ask about the appropriate method for making a claim. Until recently, for instance, if whistleblowers turned information over to an agency before informing the SEC of a problem, they were ineligible for qui tam representation.

New “safe harbor” rules recently allowed an informant to collect a $2.2 million in a case where before the government could have claimed every penny. There are many ways to protect your rights by using industry rules and legislation.

Are you considering blowing the whistle? Make sure you have the legal guidance you need before you move forward. Click to find out more about protection for whistleblowers by contacting Bothwell Law Group online.

What Do Medicare Fraud Attorneys Do with False Claims Reports?

Could you put a stop to bad billing and possibly have a chance to receive big rewards with help from Medicare fraud attorneys?  

Medicare Fraud AttorneysMedicare fraud attorneys help people fight back against health care providers and clinics that use and abuse the elderly. Bad billing practices don’t just put more money into a clinic’s pocket. They make it harder for people to get the medical coverage they need.

Are you a victim of Medicare fraud? A lawyer can help you to make a difference, potentially improving the quality of health care for people in your community. In some cases, you may even be able to collect a partial settlement for your role in stopping crime.

Why People Should Care about Government Related Fraud

Sometimes, it’s tough to take the idea of government fraud seriously. We’ve all heard the reports of the outrageous way the Pentagon, among other departments, spends absurd amounts of money. Let’s take a few moments to explain those $600 toilet seats.

Granted, there are times when government funding is gravely misused. Other times, the media twists what they know to create a sensational story. Journalists might also get the wrong idea if they don’t know how to interpret the data on which they are reporting. This happened in the 1980s when news coverage based on a Pentagon invoice hit the papers.  

What the reporter didn’t understand – or perhaps, didn’t care to mention – is the invoice was for a bulk order. The cost wasn’t assigned per item but for the lot. The result was a list of items, including a toilet seat and a jet engine, each unit priced at $600.

While certain members of the government are an exception, the pervasive overspending you might believe happens in government spending across the board doesn’t exist. Departments stretch their budgets to the limit and sometimes go without to create balance. This is especially true for health care programs like Medicaid and Medicare. When someone steals from their coffers, other individuals go without the necessary care.

Suing a Fraudulent Medicare Provider

Whistleblower laws give people just like you the chance to make a difference and reap the benefits. When you turn in false Medicare claims to a law firm, they can file a case against the business on behalf of you and the U.S. government.

Over the years, the government has used this law to clean up several industries and to clear big problems out of our workforce. From safety regulations to insider trading and now insurance fraud, whistleblowers laws improve quality of life for Americans across the board. Not only can you benefit from the decisions and the waves they make throughout the healthcare industry, but you can also collect a portion of the fines and other fees imposed on bad businesses.

This incentive has existed since the 1800s when Lincoln was desperate to find a way to stop government fraud related to war efforts. Troops were starving and freezing to death because of companies falling short on their promises. The law has changed over the years significantly. Congress has reigned in whistleblower protection and compensation for the benefit of big business, and they’ve done the opposite.

The Healthcare Industry

Today, the majority of lawsuits focus on the healthcare industry. That’s how widespread the problem is, and it hasn’t just resulted in people going without care. In some cases, providers have abused patients to justify their practices.

Under the False Claims Act (FCA), an individual can receive 15 to 30 percent of a settlement, which often goes into the millions. An attorney will explain the way the law applies today and how suing a fraudulent medical office can benefit you and your family financially.

According to the The National Whistleblower Legal Defense & Education Fund, whistleblowers filed 92 percent of the successful Medicare fraud cases in 2017, amounting to $3.4 billion dollars in funds collected by the government. The government paid $392 million to those who brought the fraud to light.

The Impact of Fraudulent FCA Filings

Unfortunately, there have been people who file maliciously against providers too, not because they think they’re breaking the law but because they’re hoping for a payoff. The result has been a breakdown in the effectiveness of FCA protection and prompting a call by the U.S. Department of Justice for Congress to enact new laws to control Medicare fraud and keep whistleblower suits out of court.

It’s essential to work with a law firm that invests time in researching and assessing your FCA case before filing. During billing, mistakes sometimes happen. Your provider might not be guilty of fraud so much as human error, and in certain situations, filing as a wronged patient makes more sense than filing as a whistleblower.

Click to find out more about Medicare fraud attorneys by contacting Bothwell Law Group online.

How Do Fraudulent Insurance Claims Affect Medicare?

Fraudulent insurance claims rob needy people of adequate healthcare.

Fraudulent Insurance ClaimsFraudulent insurance claims come in all varieties, and ultimately, it is the people who need the most who suffer more than anyone else. Substandard providers make money off the poor while delivering shoddy services. When a problem is widespread enough, policies change to limit services to keep unscrupulous medical providers from taking advantage of them. You can help preserve services and employment opportunities for those who are above-board by reporting fraudulent billing practices.

Common Types of Fraudulent Claims

It’s not always easy for a patient to identify fraudulent Medicaid billing. Providers can change someone’s address, for instance, so bills go to the wrong address. They can also be confusing for laymen to understand. However, it might help to know the main ways health providers defraud the Medicaid system.

The most common types of insurance fraud include:

  • Billing for the wrong services
  • Billing for services never provided
  • Changing the date of services rendered
  • Providing and billing for unnecessary services
  • Naming the wrong patient

Let’s go through each type of fraud and explain how it might show up on your medical bill. If you notice problems, be sure to get in touch with a lawyer who has experience in whistleblower laws. If the court finds the provider guilty, you might be able to collect a partial settlement.

Billing for the Wrong Services or Those Never Provided

Different types of medical care receive reimbursement at different rates. For instance, if you go in for a typical dental cleaning, your bill should say “Prophylaxis” instead of “Periodontal Scaling and Root-Planing.” The latter is a more labor-intensive service, so it justifies a higher payment from insurance plans.

Insurance companies know some medial practices bill incorrectly, which is why they put measures in place to justify upgraded services. For example, they might require additional x-rays or an in-depth assessment of periodontal disease before signing off on a scaling and root-planing service fee. If you’re seeing several additional services on your bill you don’t remember experiencing during your visit, there’s a good chance your bill is inaccurate.  

Some patients might shrug this off in the moment, but your insurance might only cover one of these services a year. So they won’t cover the charge if the care becomes necessary later in the year.

Changing the Date of Appointments on Medical Bills

Changing dates on medical billing is one of the latest methods dishonest doctors are using to boost their profits. They split up billing for a single visit between several different days. If you went to the doctor over a persistent cold and received an allergy test, you might get two separate bills with two different dates on them. By splitting up the services, your doctor’s office can charge the insurance provider double for office visits and associated fees.

Providing Unnecessary Services to Justify Additional Charges

Providing unnecessary services is one of the most dangerous types of insurance fraud in existence today. Instead of lying about the level of care they provided, some practitioners protect themselves against fraudulent billing claims by delivering unnecessary treatments. This seemingly ensures an airtight paper trail regardless of the type of investigation performed. Unfortunately, providers who take part in this scheme build up a tolerance to their actions over time until office staff reports the activities.

Any practice dependent on Medicaid needs to be under scrutiny to prevent these types of patient abuses from occurring. Dentists will cap every tooth in a child’s mouth or push a patient to undergo a preventive knee replacement surgery in order to bill for high-dollar services.

The problem doesn’t stop at the unnecessary risks patients undergo, or the lasting impact invasive procedures have on their quality of life. When this type of fraud is persistent, the insurance provider raises the standards of proof necessary for essential procedures. People who genuinely need them have a hard time getting them covered by insurance — if they can get them at all.  

Second opinions exist for a reason. Be sure to get one before your doctor or other health care provider convinces you to undergo an expensive procedure.

Billing the Wrong Patient

It may seem like it’s in the spirit of Robin Hood to use one patient’s access to affordable health care to provide care for someone going without the necessary care. The problem is the doctors who make these kinds of deals are often taking some sort of payment and funneling it straight to their bank accounts. Additionally, problems arise when the person whose insurance is utilized needs services of their own. Due to limits and restrictions on covered care, the real insured patient might have to pay out-of-pocket.

The coding involved in medical billing is complicated and mistakes will happen from time to time. However, when doctors or staff deal with records incorrectly on purpose, they put people at risk. Help us fight back.

Contact the skilled fraudulent insurance claims attorneys at Bothwell Law Group online or by calling 770.643.1606 today.