Contact our Georgia national whistleblower lawyers today. Call us at 770-643-1606

Judge v. Jury: $350 Million Medicare Award at Stake in Atlanta

Whistleblower attorney Mike Bothwell was a tops quoted source in the article below:

Full Article Link

The invalidation of a Florida jury’s nearly $350 million Medicare fraud verdict wasn’t only frustrating for whistleblower Angela Ruckh and her attorneys. It may have also seriously hurt plaintiffs’ ability to fight alleged fraud in the southeast U.S.

Ruckh Nov. 20 will urge the Eleventh Circuit in Atlanta to reinstate the award, which a district judge tossed after concluding she failed to satisfy U.S. Supreme Court standards for demonstrating materiality in a False Claims Act case. The federal government is supporting her appeal.

The judge misconstrued ample evidence of materiality, Ruckh says. Rejecting her appeal could do great harm to the ability of FCA whistleblowers and the federal government to raise a valid case, whistleblower attorneys say.

The decision by Judge Steven Merryday of the U.S. District Court for the Middle District of Florida “takes the most conservative and defense-oriented” view of Supreme Court standards for raising false claims cases, said Mike Bothwell of Bothwell Law Group P.C. in Roswell, Ga.

Prosecution of FCA cases will become “infinitely harder” if the U.S. Court of Appeals for the Eleventh Circuit affirms, he said.

In 2018, the U.S. recovered $2.8 billion from FCA cases, $2.5 billion of which came from cases involving the healthcare industry.

Ruckh convinced a jury in February 2017 that Medicare wouldn’t have paid Consulate Health Care, a nursing home services provider, if Medicare knew the truth about the Consulate’s practice of “ramping,” which misleads Medicare as to the necessity of services, and “upcoding” for services which led to overbilling.

Merryday tossed the verdict nine months later, ruling that the alleged misconduct wasn’t material to government payment decisions under the Supreme Court’s 2016 ruling in Universal Health Servs., Inc. v. United States ex rel. Escobar.

That is, Ruckh didn’t offer meaningful proof that Medicare’s knowledge of the disputed practices was consequential to payment decisions, Merryday concluded.

Medicare knew about the allegations and continued to pay anyway, he said.

“We don’t want every administrative failure by a contractor to be an FCA case, but when you have facts like these, where folks are receiving unnecessary services, how is that not leading to inflated, unnecessary claims,” said Pamela Coyle Brecht of Pietragallo Gordon Alfano Bosick & Raspanti LLP in Philadelphia.

“Medicare has a pay and chase system. The U.S. doesn’t examine every claim in real time. It is entitled to rely on the truthfulness of a claim submitted by a contractor, and then attempt to recoup fraudulent payments at a later date,” she said.

“It undermines the entire purpose of the FCA to say that payments to a contractor, that turn out to be fraudulent, require dismissal of cases for lack of materiality,” she said.

Consulate says materiality was indeed lacking because Ruckh offered no evidence that Medicare had overlooked any alleged deficiencies in audits before deciding to continue paying.

“If the government thought the alleged violations were material, why would they keep paying the claims? There are a host of cases now where the government ‘knowledge’ defense has been successfully raised,” said Aaron Danzig of Arnall Golden Gregory LLP in Atlanta.

‘Wild, Wild West’

The verdict should be reinstated because Ruckh introduced more than enough evidence to show that higher therapy levels lead to increased payments, and using false therapy codes has a natural tendency to influence payments, her brief says.

The U.S. Justice Department supports Ruckh, stating in a brief that materiality for her claims is “obvious,” and that “it is difficult to see how any reasonable jury could have concluded otherwise.”

Brecht said it’s “currently the wild, wild west with regard to the materiality defense, and I would hope that the Supreme Court would shed more light on this issue.”

“There are many reasons why the government would continue to pay a contractor that don’t have to do with excusing fraud,” Brecht said.

More litigation will result if the Eleventh Circuit affirms, “because whistleblowers will be forced to get more aggressive in discovery,” Brecht said. “They will be forced to say I need to know more about what the government knew about defendants’ practices and when it knew it.”

Defendants naturally will be pleased if Merryday’s ruling is affirmed.

But in the event the Eleventh Circuit sides with Ruckh, the silver lining for defendants could come in the form of another materiality case working its way back to the high court’s door.

Several defendants since Escobar have unsuccessfully petitioned the Supreme Court to adopt a clear “no harm, no foul” rule with regard to continued payments. There can’t be any fraud if the government knows but pays, the petitions have argued.

Merryday’s opinion cited one of those continued payment cases, United States ex rel. Harman v. Trinity Indus. Inc.

The Fifth Circuit ruled in that case that a $663 million jury verdict couldn’t stand because the Federal Highway Administration always paid for and approved of a highway guardrail contractor’s product despite knowledge of alleged wrongdoing.

To contact the reporter on this story: Daniel Seiden in Washington at dseiden@bloomberglaw.com

To contact the editors responsible for this story: Jo-el J. Meyer at jmeyer@bloomberglaw.com; Patrick L. Gregory at pgregory@bloomberglaw.com

Whistleblowerlaw.com & Mike Bothwell Lawfirm does not claim or imply ownership of this article. Full article link here: https://news.bloomberglaw.com/federal-contracting/judge-v-jury-350-million-medicare-award-at-stake-in-atlanta

Trump & our thoughts on why we should protect Whistleblowers

USA Today recently published the following article “Trump’s allies want to ID the whistleblower, who may learn the price of speaking out“.

Here are our my thoughts.

Shortly after signing the Declaration of Independence, the Continental Congress passed a resolution for whistleblower protection.  Some sailor and marines blew the whistle on a commander of the navy during the war with Great Britain.  They reported the problems to the Continental Congress and were prosecuted for it.  The Continental Congress not only passed the resolution supporting blowing the whistle on such abuse (calling it a “duty”), but it passed a subsequent resolution to pay the costs of their defense.

Another major whistleblower legislation was passed in 1863 during the Civil War.  The False Claims Act also known as the Lincoln Law allowed private citizens to sue on behalf of the government to recover for false claims and fraud against the government.  This law was significantly revised in 1985 and has become the government’s number one tool for prosecuting fraud against the United States.  Whistleblowers recover from 15% to 30% of what the government receives and cases under the False Claims Act have brought in $60 billion since it was revamped in 1985.

Various state and federal agencies have passed whistleblower protections and evinced a consensus that whistleblowers play a crucial role in ferreting out fraud, waste, and abuse in our system.  In 1985, when Congress was considering one of the oldest and most robust whistleblower statutes (the False Claims Act), it noted that the act was underutilized in large part because of fear of retaliation.  That is perhaps the number one deterrent to people shinning a light on corruption and illicit dealings.  From July 30, 1778 to the present, America has agreed to protect people who are willing to bring bad things to light.

We absolutely need to continue this protection. I’m fighting for this daily.

Healthcare Whistleblowers Know a Kickback Scheme When They See One

Healthcare Whistleblowers: Let’s talk about the key signs of kickback schemes, and what to do when you see one.

Healthcare WhistleblowersYou’re a healthcare worker who is considering joining the ranks of healthcare whistleblowers. You’ve been in the game long enough to know a kickback scheme when you see one. You’re pretty sure that something illegal is going down in your workplace or with one of your clients. Here are some signs of kickback schemes to help confirm illegal behavior.

Signs of a Healthcare Kickback Scheme

You might think you know what a kickback scheme is until you need to report one. That’s when the doubt can creep in and make it seem a little less cut and dried. Take a look at some signs of a healthcare kickback scheme to help give you clarity:

You’re seeing patients referred for care that they don’t need.

One of the most common methods of kickbacks is agreement with a physician or company to refer patients with the goal of collecting government medical care income. These referrals happen even when the patient doesn’t need the service. Many patients don’t question whether they need care, especially when their insurance covers it. The specialist receives the Medicare payment for the test. The referring doctor receives a pre-agreed upon cash kickback or part of the Medicare payment. This may require you to do a little – or a lot – of research. When you’re seeing patients referred for tests, a simple search can give you more information on the purpose of the test.

Cash is coming in, but it doesn’t show up in the books.

If you run the business side of things, you might notice extra income coming into the business. Be especially concerned with cash payments that do not fit with services rendered. This can be tough to track if you work in an office where cash payments are common. It’s easier to prove this as a part of a kickback scheme if your patients typically use insurance or pay using credit cards.

You see referrals for care before a healthcare professional even meets with the patient.

It a doctor refers a patient without seeing them, a kickback scheme could be in progress. A doctor needs to meet with a patient to assess their condition before deciding what types of testing might be necessary. If you’re asked to call and set up a referral appointment before the patient sees a doctor in the practice, it’s possible that it’s a kickback arrangement.

Giving the same diagnoses to patients with very different symptoms.

It’s possible that the company or care provider that a doctor has an agreement with only treats one type of condition. The diagnosis of the particular condition must be in their file for the Medicare money to come through. If this is the only indicator you’re seeing, be aware and keep your eyes out for more similar cases and diagnoses.

Gathering Information

If you’re working at a healthcare office where a kickback scheme is in place, it may seem obvious to you that something illegal is happening. If this is the case, it’s critical that you gather evidence. Small nuances, offhand comments, and small financial details can all add up during an investigation. Keep track of the services or diagnoses you’re questioning, the provider at fault, the dates of service, and the reasons that you believe Medicare shouldn’t have paid for the service in question.

Why Not Report Anonymously?

As a healthcare professional, you know that you have the option to report healthcare fraud anonymously. This can prevent your employer from ever finding out that you were the one who filed the suit. Why should you file a qui tam suit? When you file without hiding your identity, the government can talk with you and get more information, helping them to hold the guilty party accountable.

As a way to encourage citizens to report fraud, qui tam laws also entitle reporters to a percentage of the money that the government recovers in the suit. They will also protect you from job loss and employer retaliation. If you lose your job due to reporting, qui tam laws will help you get reinstated. There is also the potential for double back pay for wages lost during the time you were out of work might.

If you’re aware of healthcare fraud including kickback schemes, you know that you need to do the right thing: report it. Qui tam laws will protect you, and our qui tam lawyers will help. We know how to get you the money you deserve for doing the right thing and reporting fraud. Find out everything you need to know about healthcare whistleblowers by contacting Bothwell Law Group.

Where Medical Insurance Fraud Cases Run Rampant, and How to Spot It

Prevent medical insurance fraud cases from robbing people in need of the care they deserve.

medical insurance fraud casesMedical insurance fraud cases don’t represent a victimless crime, and it doesn’t just affect big corporations. These types of crimes are directly responsible for shrinking benefits and higher costs. People who need insurance coverage get dropped every time insurers make adjustments. Anyone has the ability to make a difference by stopping insurance fraud in its tracks. Depending on the circumstances, doing so might add a few zeros to your bank balance.

Most Common Types of Healthcare Insurance Fraud

  • Billing for care never the professional didn’t provide
  • Misrepresenting details of care
  • Providing unnecessary care or prescribing unnecessary medication
  • Incorrectly diagnosing patients to substantiate expensive treatments
  • Failure to collect copayments
  • Offering kickbacks

The Most Common Problems

In over half of fraud cases, health care providers bill for services they never performed. The most worrisome cases involve multiple patients who many times suffer from some sort of disability. Their impairment makes them vulnerable to fraud or to threats by medical professionals who don’t want them to discuss what is (or rather, what isn’t) going on behind closed doors.

In many cases, patients don’t even see the provider. The visit is simply added to their bill. Offices then falsify patient records — or not. Investigators report that a majority of fraud cases get closed quickly because there is zero documentation to back up their false bills.

Both of these situations can be difficult to pinpoint unless you know a patient well. If you’re an in-home care provider, for instance, you can talk with the patient at length about what happened during their appointment and compare it against the bill. Likewise, if bills are arriving for dates and services the patient wasn’t involved in, there’s sufficient reason to ask more questions.

Misrepresenting Details of Care

When it comes to misrepresentation, many healthcare providers tell themselves they’re doing the right thing. They fudge dates or treatment types to ensure someone is paying for procedures their patients need. They might change locations or staff names around to ensure payments get spread around. People who benefit appreciate the results, so they rarely say anything to put a stop to it. However, most fraudsters don’t stop at simply helping their patients. They help money into their own pockets.

Take, for instance, the practice of changing dates. Clinics might perform two or three types of treatment during a single visit. The bill would include an office fee, exam fee, and specific treatment expenses. An office might choose to split this bill into three visits, each with their own office and exam charges.

Other Types of Fraud Can Hurt Patients

Other types of misrepresentation are dangerous for patients. For example, a fairly common type of fraud involves claims for therapy or treatment happening onsite when the patient performs it at home on their own. This can range from physical therapy to injections and wound care. Many of these practices aren’t covered by insurance because they’re not considered safe.

In other cases, doctors sign off on care that’s provided by staff without proper training. These kinds of clinics often bring in legitimate health providers to act as supervisors without letting them in on the details. Once they realize they’re dealing with an illegal operation, they might be too afraid of repercussions to come forward.

If bills come to your home detailing treatment performed on the wrong dates, in the wrong locations or in different ways than they’re delivered in reality, ask your health professional for an explanation. Medical billing is complicated and human error might have played a role, but there’s likelihood of fraud if it keeps happening.

Other types of fraud are becoming less common, but they are some of the most damaging in the industry.

How Fraud Robs Patients in Need of Critical Care

Throughout the 90s and early 2000s, one of the most common types of medical insurance fraud was writing bad prescriptions. Patients who didn’t need heavy-duty painkillers would get them, sell them and pay the doctor a little extra. Those scams are much less prevalent today because the government has gone out of its way to catch them. Unfortunately, it highlights exactly how fraud can cost patients in need.

The majority of community healthcare centers – facilities where low-income families go to receive the care they cannot afford anywhere else – do not prescribe pain medication. Urgent Care units won’t either. It takes an expensive trip to a family doctor or specialist to receive adequate pain management, and even then, a doctor might refer a patient to a specialty office. Few doctors will deal with the scrutiny of prescribing those kinds of drugs, even when they have a patient who would greatly benefit from taking them.

Access to quality, necessary care is at stake, and anyone can help secure it. If you’ve seen a business or health provider engaging in fraud, you have the ability to stop it.

Click to find out more about medical insurance fraud by contacting Bothwell Law Group online.

The Case Against Hospice Fraud Gets a Little Bit Murkier  

Hospice fraud has taken a hairpin turn into the hard-to-prosecute, harming honest hospice care providers, the government and whistleblowers alike.

Hospice FraudIn our evolved and humane culture, it’s only right that our elderly and terminal patients have a pleasant, government-supported place to spend their final days. Yet in the wake of the Affordable Care Act, it seems many hospice care centers have chosen to capitalize on the unprecedented potential of Medicare payments by filing claims that result in hospice fraud.

Among the companies under the microscope recently are Palliative Services of the Treasure Coast and Horizons Hospice. Both of them paid millions of dollars in fines for false Medicare claims, explains Home Health Care News. Given this, the U.S. Department of Health & Human Services Office of Inspector General is now cracking down on hospice centers. They are more determined than ever to ensure government money gets spent wisely.

Yet the case is not that simple.

A Troubled Trial from the Start

The trial against AseraCare is a perfect illustration of how difficult it may prove to come to a decision over hospice care fraud. Among her various decisions over a several-year period, Judge Karon Owen Bowdre did anything but clarify or streamline the case. Her actions over that time include:

  • Splitting the case into two separate trials to address a) the fraud allegations and b) to treat the rest of the claims against AseraCare
  • Assertions she did not provide adequate instructions upfront, leading to the judge overturning the jury’s finding that AseraCare submitted 104 of its 121 claims falsely
  • Tossing out the case entirely, stating that with the vast disagreement over whether or not a patient is terminally ill, it’s impossible to prove the falsity

Today, the decision rests with the 11th Circuit Court of Appeals, but the timeline is hazy at best, nonexistent at worse.

The result, to say the least, is massive confusion across the industry. Honest providers feel targeted and insecure. They are uncertain how to “ensure” their patients will really live six months or less. On the other hand, dishonest providers are happy to jump at the chance this troubling case provides. Whistleblowers, lastly, feel understandably helpless.

Confusion Persists, but Injustice Doesn’t Have To

Despite the recent claims that prosecuting hospice fraud grows ever more impossible, that’s not the case. Are you are a whistleblower concerned about injustice and misuse of government money? There is a place for you in the courtroom.

Come see us at Bothwell Law Group, where we dedicate all our energy to representing qui tam whistleblowers. A successful claim can mean rewards for you and support of the U.S. government, so don’t wait. Call us at 770.643.1606 today.

What You Need to Know About Medical Insurance Fraud in Hospice Care Before You Blow the Whistle

Medical insurance fraud in hospice is a significant source of whistleblower claims.

medical insurance fraud in hospiceMedical insurance fraud in hospice shouldn’t be a surprise. Fraud can occur anywhere, whether it’s a routine doctor’s visit for a healthy person or hospice care for someone who is terminally ill. Some patients will have private insurance to pay for the costs of hospice care. However, most patients seeking hospice care will pay for it through a government program, such as Medicare, Medicaid or Veteran’s Health Administration.

With the extent government money helps pay for hospice care, it’s not surprising that fraud may occur. Have you witnessed fraud and want to report it? Keep the following information in mind so you fully understand what you’re getting into and what you need to do.

What Is Hospice Care?

The exact definition of hospice care will usually depend on the policies and rules set in place by Medicare and Medicaid. However, generally speaking, hospice care includes emotional support and pain management services for those who have a terminal illness and do not expect to live for more than another six months. In the United States, about two-thirds of patients will receive hospice care services in their home.

Just because hospice care refers to someone who is about to pass away, that doesn’t mean government fraud is any less likely. In fact, it might be a little bit easier because of the increased difficulty of detection.

Why Fraud During Hospice Care May Be Difficult to Detect

One reason why illegal billing may be harder to discover for hospice services is due to the sensitivity of the care. Because hospice care concerns an individual who will very likely pass away soon, it may be more uncomfortable for an individual to speak up when something improper takes place.

For example, let’s say you’re a hospice nurse and you know that your patient should receive six pain pills per day. Because your patient receives his hospice care at home, it’s inevitable that a family member will help provide care, including administration of pain medications. You also know that the bottle containing 48 pain pills should last eight days. However, it runs empty after just seven days. So apparently someone either miscounted the number of tablets in the bottle when filling the prescription, the patient is receiving more pain pills than medically necessary or someone is stealing the pain pills.

A Sad Situation Can Get Worse

Over the next few weeks, you decide to pay extra close attention to the bottle of pain medication. You soon discover that it’s a family member that’s stealing some of the pain pills. They are selling them on the street for cash. They’re trying to help pay for other necessary medical expenses not paid for by Medicare or Medicaid. But the day you finally make this discovery, your patient dies. So confronting the family member stealing the pills is probably a bad idea, at least right now. Also, even if you report the family member, they’re stealing the pills to help pay for other medical expenses for their loved one, not for personal profit.

Is healthcare fraud taking place? Probably. Is this something worth reporting? If you do things by the book, then yes, it is. But if the appropriate action takes place, the family member may have to mourn the loss of their loved one from behind bars. This puts you in a difficult position and makes it much easier to not report it and let it slide.

Another reason why it’s extra hard to find fraud in hospice care is because it often takes place at home. This means several things. First, there are fewer medical professionals around the patient. Second, any necessary paperwork is more likely to be accessible by a family member or non-medical professional. Third, given the home setting, it’s easier to ignore or bend any medical rules and procedures. This doesn’t mean impropriety must take place at home during hospice care, but the potential is there.

What This Means When Serving as a Whistleblower

It may be harder to detect Medicare or Medicaid insurance fraud in a hospice setting. Therefore, you’re taking a bigger risk as a whistleblower. Let’s say you’re not calling attention to the fraud for the potential qui tam reward. You only want to do the right thing. You’re still at a higher risk of looking like a bad person who is trying to drag a family or healthcare provider’s name through the mud.

If it’s harder to detect hospice care fraud, then that will also probably mean it will be harder to obtain evidence of the fraud. The result is that if you blow the whistle on someone, you will have greater difficulty proving fraud. This isn’t always going to be the case. But when you’re debating whether or not to report, it will be something to consider.

Want to Speak with an Attorney Experienced with Medical Insurance Fraud in Hospice?

The above information is just something to think about when blowing the whistle. To make the most informed decision possible, you’ll want to speak with an attorney. Look for one who handles medical insurance fraud in hospice care. Contact our skilled medical insurance fraud attorneys at Bothwell Law Group by calling 770.643.1606 today.

Why Kickbacks Are So Common in Medical Insurance Fraud

Medical insurance fraud commonly comes in the form of kickbacks.

medical insurance fraudHealth services make up a large portion of the American economy, so medical insurance fraud is a common occurrence. Kickbacks are one of the most common forms of illegal behavior in the healthcare setting, but why is this the case? And what are kickbacks, anyway? Read on to find out.

What Are Kickbacks and How Do They Work?

A kickback is similar to a bribe in that one party will pay another party for improper benefits. Looking at an example is the best way to understand what a kickback is.

In a hypothetical healthcare setting, let’s say you have the patient, the patient’s primary care physician, the patient’s insurance company and a doctor who focuses on treating arthritis (we’ll call this doctor “John”). Now let’s assume the patient suffers from joint pain and goes to see his primary care physician. After an examination, the primary care physician believes the patient might have arthritis and refers the patient to Doctor John. The patient sees Doctor John and receives medical treatment. Along the way, the patient’s insurance company pays each doctor for the medical services they provide.

In a hypothetical involving a kickback, the patient’s primary care physician examines the patient. But instead of referring the patient to Doctor John, refers him to Doctor Bob. In return for referring the patient to Doctor Bob, the primary care physician receives a payment from Doctor Bob as a “reward” for sending him a new patient. In this example, the payment Doctor Bob sends to the primary care physician is a kickback.

Why Are Kickbacks Common?

One reason why kickbacks are so easy is that they’re easy to hide. Looking back at the above example, Doctor Bob and the primary care physician could be great friends who spend a lot of time together, perhaps playing golf once a month. During each of these golf games, Doctor Bob puts a roll of unmarked $20 bills in the primary care physician’s golf bag when no one is looking.

Unless the physician tells someone about this kickback, there will be almost no way to identify or trace those unmarked bills. Do you think the primary care physician is going to record the cash in the office business ledger or report it to the IRS as taxable income? The answer is no. An individual can easily hide a few hundred dollars per month of ill-gotten gains by simply using the cash for ordinary purchases. In fact, the primary care physician’s spouse probably won’t even know about it.

But one of the biggest reasons why kickbacks are so common is the nature of the healthcare system in the United States. Before a patient can see a doctor who focuses on a particular area of medicine, they need a referral. In other words, if a patient wants to see Doctor B, they must first see Doctor A.  That doctor will give them a referral to see Doctor B.

In a perfect world, Doctor A will always refer patients to the best doctor, whether it’s Doctor B, C or D. Who Doctor A ultimately chooses is a judgment call. Doctors may not be able to provide a plausible reason to explain why they choose to refer a patient to one doctor and not another. This means it’s very easy to set up a situation for kickbacks.

Kickback Coverups

The only difficult part is covering up the kickback itself. As long as the kickback is small, it can probably remain hidden. But healthcare in the United States is expensive. With so much money flowing in and out of hospitals, doctor’s offices and clinics, it’s hard to keep track of it all. On top of that, the medical and financial records created from just one doctor’s visit are immense. Anyone would have trouble sorting through to catch a kickback scheme in action.

This is especially true in cases where a person has numerous medical procedures and bills or is in under medical care for a long period of time. Think of a person who undergoes cancer treatment, then spends several months in hospice before their death. That could be a good example of a case where unscrupulous providers could bill much more than they actually should.

In many situations, only an individual with a very detailed understanding of the financial operations of a healthcare facility can identify a kickback scheme. This is why whistleblowers are so important to stop kickbacks.

Looking for Additional Information about Fraud Related to Medical Insurance?

Click to find out more about medical insurance fraud by contacting our team at Bothwell Law Group online.

What Types of Healthcare Fraud Are Most Commonly Reported under Whistleblower Legislation?

Types of Healthcare Fraud

Types of Healthcare FraudThere are many types of healthcare fraud, and the United States government relies heavily on whistleblowers who report fraudulent activity. Anytime a healthcare provider uses misrepresentation on an insurance claim, this is fraud. The False Claims Act makes it possible for healthcare employees to report evidence of fraud in their workplace. Healthcare fraud costs millions of dollars every year.

If you are an employee at a healthcare organization, you can keep an eye out for these most commonly reported health care fraud activities and aid in recovery of government funds:

Health Care Fraud Scheme #1: Billing for Service or Product Never Provided

In some cases, physicians or billing departments will attempt to collect additional money by billing Medicare or Medicaid for services or products they never provided to a patient.

Health Care Fraud Scheme #2: Separate Billing of Services Normally Bundled as One

Many diagnostic tests and procedures are commonly bundled together as one on insurance claims. In some cases, healthcare providers will bill for the bundled procedure and then unbundle the service and bill for each test individually in order to obtain double payment.

Health Care Fraud Scheme #3: Double Billing

In some cases, healthcare professionals may try to bill for a service more than once, as a way to make more money.

Health Care Fraud Scheme #4: Incorrectly Diagnosing a Patient

There are some healthcare services that are only provided by Medicare or Medicaid when the patient has a specific diagnosis. In order to obtain payment for a higher paying procedure, some health care professional may falsely diagnose their patient.

Health Care Fraud Scheme #5: Billing an Uncovered Service as Covered

This type of fraud often happens when a physician is doing a favor for a patient. They want to provide a non-covered service for the patient. Therefore, they bill it as a covered service. Even though motivated by their desire to help out their patients, it is still healthcare fraud.

Health Care Fraud Scheme #6: Accepting Kickbacks from Vendors

The pharmaceutical and medical supply industry is a highly competitive business. Because of this, some vendors may engage in unethical activity to bias physicians to use their product. Anytime a physician accepts a kickback or bribe from a vendor, they commit healthcare fraud.

Health Care Fraud Scheme #7: Use of Unnecessary Services

In some cases, physicians will provide patients with unnecessary services or products normally paid by Medicare or Medicaid. This allows them to receive payment for services they never should have performed.

If you work at a healthcare organization and you suspect your employer may be committing one of the fraudulent activities listed above, you can file a complaint under whistleblower legislation. The laws in place enable to whistleblowers to file a lawsuit on behalf of United States government. Whistleblowers can receive protection from retaliation at the hands of their employer. Also, they may receive a portion of the recovered funds.

Have questions about the different types of healthcare fraud that exist? Click here to get the answers you need from our team at Bothwell Law Group.

How Insurance Agents Identify Fraudulent Insurance Claims

fraudulent insurance claims

fraudulent insurance claimsEach year, somewhere between three to ten percent of money spent by the government on healthcare is spent on fraudulent insurance claims. Fraudulent insurance claims are becoming increasingly common. However, that doesn’t mean they have become easy to spot. In fact, the individuals committing Medicare insurance fraud have learned how to hide their fraudulent activity well.

What Are Some Signs of Medicare Fraud?

The United States government relies heavily on individuals who are willing to blow the whistle on providers who are committing fraud and stealing money from Medicare. Because of this, insurance agents are learning to be hyper-vigilant. They watch closely for suspicious activity in each and every claim they manage. Insurance agents are learning to identify fraudulent insurance claims by watching for the most common types of Medicare insurance fraud, which include:

Duplicate Billing

In many cases, healthcare professionals will try to bill for a service more than once as a way to make more money.

Separate Billing of Services Normally Billed as One

There are specific procedures, such as diagnosed blood tests, which are typically billed as one. For instance, a complete blood count contains multiple tests but is almost always billed as one procedure. Healthcare providers may bill the CBC tests as one, and then bill for each test in order to receive double payment.

Billing for Services Never Received

In some cases, healthcare professionals will bill Medicare for services a patient never received. Medicare insurance agents can watch for billings that seem out of place or do not match up with a patient’s health history.

Medicare ID Sharing

More frequently, Medicare ID numbers are being shared among multiple people. Healthcare providers may also use them to bill for services for patients they haven’t seen. Insurance agents watch carefully to make the ID number being uses matches with the name on the claim.

In addition to watching for the most common types of Medicare insurance frauds, insurance agents carefully consider the calls they get from Medicare clients. People may call with concerns or confusion concerning a claim description they received in the mail. This red flag signifies the possibility of fraud. The client is the most reliable source for understanding which billings are accurate. So, insurance agents should never dismiss their concerns about inaccurate billing.

What Should You Do If You Suspect Fraudulent Insurance Claims?

If you are an insurance agent or patient who has concerns about a health provider, speaking with a fraud attorney who has extensive experience working with fraudulent insurance claims is a good place to start. A team member at Bothwell Law Group can look carefully at your suspicions. Then we can help you determine whether you have grounds for a lawsuit.

Contact our skilled fraudulent insurance claims attorneys at Bothwell Law Group by calling 770.643.1606 today.

Top Medical Insurance Fraud in the News

Medical Insurance Fraud

Medical Insurance FraudOf all cases of medical insurance fraud that occur each year, Medicare fraud is the largest source. In 2014, fraudsters scammed Medicare for over $60 billion, and over 2,000 providers have been caught defrauding Medicare. Pursuing Medicare fraud can be difficult due to the prevalence of fraud as well as the sheer number of people involved in defrauding Medicare.

What Is Medical Insurance Fraud?

Medical insurance fraud occurs when a provider or consumer intentionally submits fraudulent information that is used to determine health care benefits payable. Because of the cost of health care and medical equipment, the idea of pocketing the payout of billing for services or equipment that were not rendered is a tempting one for providers and consumers alike. While Medicare is the organization that is most affected by fraud, it can affect any heath insurance company, and can be perpetuated by individual doctors as well as organized groups.

Medicare and related government-provided coverage is the most common target for insurance fraud for a few primary reasons:

  • Over 54 million people are covered by Medicare, and the organization pays out over $600 billion each year.
  • The organization is subjected to the loosest monitoring by those in charge.
  • Billions of dollars are left largely unguarded and ripe for targeting by scam artists.

How Is Medical Insurance Fraud Perpetuated?

There are various ways providers and consumers can commit medical insurance fraud. Some of the most common seen by investigators include the following:

  • Billing for medical equipment, medication, or services that were not actually rendered, received, or performed.
  • Falsifying a patient’s diagnosis to justify procedures, equipment, surgery, or other procedures that were not medically necessary.
  • Upcoding and Unbundling. Upcoding is billing for a service more costly than the one performed. Unbundling is the billing of each step of a procedure as separate procedures.
  • Accepting kickbacks in exchange for patient referrals.
  • Waiving co-pays or deductibles and over-billing the insurance company.
  • Forging or alteration of medical bills or receipts.
  • Using someone else’s health coverage or insurance card.

Combating Medical Insurance Fraud – a Lengthy Process

Medical insurance fraud is a crime that has serious ramifications for everyone. Every time fraud is committed, it raises the cost of health care for millions of other Americans. So it is important that medical insurance fraud is pursued and prosecuted in order to recoup the amounts that were defrauded.

The challenge in pursuing insurance fraud is finding individuals who are both willing to cooperate with investigators and who have sufficient evidence to back up their claims. Even when a whistleblower contacts authorities with information, it can be a long and arduous process to gather more evidence and bring a court case. But these cases must be pursued in order to help combat the rapidly-rising costs of health care in the United States.

If you have witnessed or participated in medical insurance fraud, you will need protections should you choose to come forward as a whistleblower. Contact the skilled whistleblower attorneys at Bothwell Law Group by calling 770.643.1606 today.

3 Steps to Follow when You Need to Know How to Report Healthcare Fraud

how to report healthcare fraud

how to report healthcare fraudIf you’re wondering how to report healthcare fraud, you’re probably already in an uncomfortable position. Someone you work for (or with) is doing something illegal to defraud the government and the healthcare system it supports. You’ve found out, and now you think you need to do something about it.

Here are the steps you should follow if you ever think you need to file a report:

How to Report Healthcare Fraud:  Gather Evidence

When reporting any fraud or misconduct, you need more than just hearsay. Ideally, you’ll have a paper trail consisting of invoices, vouchers, emails, database records, and any other physical items that paint the picture about what exactly is going on.

Once you have everything in order, do not talk to anyone about it yet. Not a friend, not your company, and not the press. This is important because the instant you disclose certain information, you lose options. You also potentially implicate yourself in contractual and non-disclosure violations.

Simply gather the information for now, and keep it in a safe place.

How to Report Fraud:  Understand Your Options

You have three main options when it comes to reporting suspected fraud:

  1. Notify the agency being harmed. Each agency has its own Inspector General, responsible for investigating any fraud relating to their department.
  2. Notify the FBI. You can always report fraud anonymously through the FBI tip hotline, or by contacting your local FBI office.
  3. File a qui tam lawsuit under the federal False Claims Act. Under the FCA, individuals can file a civil lawsuit on behalf of the U.S. government.

The first two options above are fairly straightforward, and are certainly good choices in specific and simple scenarios. However, the third option is potentially the most lucrative of the three.

How to Report Fraud:  Consult a Qui Tam Lawyer

In the event you need help making the best choice, or you’ve already decided to file a qui tam lawsuit, it’s time to consult a lawyer. Your lawyer can review the evidence you’ve provided, and help you determine if it’s enough to bring a lawsuit. What your lawyer is looking for is the strength of the evidence, and the size of the fraud in question; both factors will determine your likelihood of success

After reviewing the evidence, your attorney will likely advise on which of the three options is in your best interest given the facts of the case. In the event you decide to proceed with a lawsuit, you can expect them to do the following:

  • File a complaint with the U.S. District court under seal. The term “under seal” means only the government and you are aware a suit has been filed. It gives them time to conduct their own investigation
  • Work with the government to help determine if they want to join your case
  • Carry your case, working with the government (in cases where they intervene), on your behalf

Anything Else You Need to Know about Healthcare Fraud Reporting?

Still have questions about how to report healthcare fraud? Click here to contact the Bothwell Law Group online.

What the False Claim Act for Healthcare Means to You

False Claim Act for Healthcare

False Claim Act for Healthcare The False Claim Act for healthcare is essentially a small component of a much larger set of regulations making it a crime to knowingly record or file a false claim, regarding any federal healthcare program. While Medicare and Medicaid are both considered federally funded programs, it also extends coverage to any plan or program providing health benefits (including through insurance) which receives any funding from the federal government or state-sponsored healthcare system.

Examples of fraud covered under the FCA include billing for services never received, double billing (billing for the same service more than once), or making any sort of false statement in an effort to obtain payment for services.

Penalties Associated with Falsifying Claims

Any violation discovered and prosecuted under the FCA carries stiff penalties. From a financial perspective, an individual or organization is on the hook for three times the amount of the falsified claim, plus an additional penalty of up to $11,000. These penalties are on a per claim basis, so in cases of systematic fraud, the dollars begin to add up quickly.

Violations can also be counted as a felony charge, and result in jail time, additional fines, or both. Anyone found to have received a benefit by way of fraud, made a fraudulent statement, or worked to conceal material facts can be held liable.

Protection for Individuals Reporting Fraud – aka – Whistleblowers

Any employee who reports a violation under the False Claims Act is legally protected from harassment, suspension, or being fired as a result of their reporting. If the court finds the employee did suffer discrimination, they may be awarded two times their back pay (with interest), immediate reinstatement of their original job, and additional compensation for costs incurred and any damages suffered as a result.

When the Qui Tam Provision May Apply

Qui tam is an abbreviation for a Latin phrase that very loosely translates to someone who brings a case on behalf of themselves and their “king”. Basically, it means you can sue someone on behalf of the government, and be paid a percentage of any of the funds recovered as a result of the lawsuit, even if you were engaged in, or a part of, any illegal activities covered by the FCA.

It is worth noting here that any awards received as qui tam payments are considered ordinary income, and taxed as such by IRS. While previous qui tam relators have attempted to have these payments classified as capital gains, the Ninth Circuit Court of Appeals upheld the IRS’ position on income classification.

Think You Have a False Claim Act for Healthcare Case?

Contact the experienced attorneys at Bothwell Law Group by calling 770.643.1606, and find out if the False Claim Act for healthcare applies to your situation.