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What Is the False Claims Act and How Does It Affect Medicaid?

Learn how the False Claims Act and Medicaid work in tandem.

the False Claims ActThe False Claims Act is well-suited to deal with current Medicaid problems. Surprisingly, the law came out of the Civil War to combat other types of government fraud. The principles still hold true today. Furthermore, the government uses them more often to prosecute businesses and individuals who attempt to defraud the government’s healthcare system.

History of the False Claims Act

While many people think of whistleblowers as a construct of the 20th century, there have always been people willing to risk it all for the greater good. Instead of expecting them to sacrifice their livelihood to ensure the safety and security of the masses, politicians decided early on these people should have special protection.

The False Claims Act is also called the “Lincoln Law.” Abraham Lincoln, the 16th U.S. President, enacted the law in 1863 to stop corruption during the Civil War. The leading minds of the time couldn’t fathom corrupt individuals living high on the hog when boys were fighting with the barest essentials.

The passing of the False Claims Act was a pivotal moment in U.S. history where the country distinguished itself and its values in a way many have forgotten today. Fortunately, the law holds and serves to protect individuals who speak out in an effort to keep the country’s resources from going to waste.

What about Qui Tam Lawsuits?

The act introduced “qui tam” lawsuits, allowing private individuals to sue those defrauding the government on the nation’s behalf. At the time, whistleblowers (known as “relators”) received half of the damages assessed by the courts. That changed in 1943, which had a drastic impact on the number of false claims reported. It also restricted qui tam eligibility to cases where the government had previous information, even when the relator was the source.

The 1940s revisions to the False Claims Act left the legislation virtually impotent against government corruption. Over the next 40 years, the gaps the changes left in accountability created a widespread problem, particularly in regard to defense contracts. During the Reagan Administration, the military came under fire for paying exorbitant amounts of money for basic items.

Scores of contractors were suspect, but investigators ran into brick walls — or rather, walls of employees too afraid to talk. Congress worked diligently to rework the False Claims Act to make whistleblowing more enticing, providing job protection, regranting qui tam eligibility for individuals who had previously informed the government of the fraud and ensuring relators received 15 – 30 percent of judgments. It’s working.

In 2015, the Department of Justice awarded a whistleblower nearly $2 million in a judgment against a children’s hospital that misstated the number of beds it had available in order to qualify for grant funding. Between repayment, penalties and fines, the government reclaimed $12.9 million.

Using the False Claims Act to Fight Medicaid Fraud Today

Medicaid is a federal and state healthcare program for low-income individuals and those with disabilities. It covers approximately 74 million people in the U.S. The complicated structure of the program leaves it ripe for fraud and other types of correction.

The most common types of Medicaid fraud committed by facilities, organizations and healthcare providers include:

  • Performing unnecessary procedures
  • Billing for procedures never performed
  • Writing unnecessary prescriptions
  • Using improper billing codes to increase fees
  • Offering referral fees or kickbacks
  • Knowingly treating the wrong person
  • Knowingly treating someone who shouldn’t qualify

The most common types of Medicaid fraud committed by patients include:

  • Providing false information on Medicaid applications
  • Altering prescriptions or requesting unnecessary medication for resale
  • Taking money from a facility or professional in exchange for unnecessary services
  • Using multiple Medicaid cards under false identities
  • Loaning Medicaid cards to those who don’t qualify for coverage

As you can see, in certain situations an individual would be able to file a suit against any number of players in the Medicaid fraud game. The Department of Justice is going after the biggest offenders, and they’re winning big.

In April, for instance, the DOJ won an $18 million settlement against Banner Health after an investigation showed four hospitals regularly provided unnecessary treatment for patients in order to increase their Medicaid bills. A whistleblower received over $3 million in the case and helped stamp out corruption that ultimately robs people of the care they deserve.

Do you have proof of Medicaid fraud? Speak out before someone else beats you to the punch.

Contact the skilled False Claims Act-Medicaid attorneys at Bothwell Law Group by clicking or calling 770.643.1606 today. We are here to help you consider your best legal options moving forward.

What You Should Know Before Becoming a Medicaid Fraud Whistleblower

Before becoming a Medicaid fraud whistleblower, consider the following.

Becoming a Medicaid Fraud WhistleblowerIf you notice Medicaid fraud, you may think about becoming a Medicaid fraud whistleblower. You want to do the right thing, and the possibility of a substantial financial reward doesn’t hurt either. But before you blow the whistle, keep the following considerations in mind, because the whistleblowing process isn’t always pretty. Also, it is something that is very hard to stop once it begins.

Retaliation Is Likely

If you decide to be a whistleblower for Medicaid fraud, there’s probably a lot of money at stake. And when that large amount of money stops flowing to the people engaging in the scam, many people will be angry. And on top of that, many people will view you as a traitor, even though you’re doing the right thing. So after blowing the whistle, they will be very upset with you and try to get revenge. This means retaliation is a strong possibility.

The retaliation might be minor or subtle, such as your lunch going missing from the office refrigerator. Or maybe your cubicle mates stop inviting you to drinks after work. But the retaliation can also be very serious, such as a demotion, a drop in pay, physical violence or firing. This is illegal, but it’s often tough to prove. Also, the legal remedies for retaliation aren’t always enough to make it worth being a whistleblower.

A Big Cash Payout Isn’t Easy to Get

In special whistleblower cases, like a qui tam action, you might serve as a “relator.” This is a specific type of legal case. In it, you sue the person or company committing the fraud on behalf of the federal government. And in return for your assistance by becoming a Medicaid fraud whistleblower, you can get about 25 percent of the total amount of money the government is able to recover.

This is an excellent financial reward. It can sometimes be in the tens of millions of dollars, especially in Medicaid qui tam actions. But before you start dreaming about retirement, there are some things to consider. First, you will have to earn that money. Qui tam actions are complex civil lawsuits. You will have to provide a great deal of assistance to the federal government in building a case against the person or company committing the fraud. You should expect to spend a lot of time answering questions and producing documents and other forms of evidence of fraud.

These Cases Take Time

Second, qui tam actions can take a long time to complete. It might be years until it finishes and the federal government recovers some or all of its money. So that’s a long time to litigate a qui tam case and deal with the potential retaliation.

Third, even if you are successful in your qui tam action, the government may not be able to recover as much money as you thought. Perhaps your former boss improperly took $100 million by defrauding Medicaid. But if the federal government recovers only $1 million and your reward is 25 percent, that’s only $250,000 to you. This is a lot less than the $25 million you were hoping to get. Then there’s the fact that it might take three years to get that money and because you were a whistleblower, you lost your job. You need to ask yourself if those three years and a lost job are worth the $250,000.

A Simple Anonymous Phone Call May Not Be Enough

If you want to be a successful whistleblower, you should expect to do more than send off an anonymous email or phone call to the proper authorities. Sometimes this may be enough. An easy investigation quickly uncovers tons of fraud with plenty of evidence to convict and sue everyone involved. But this usually isn’t the case.

It’s very possible that when the federal government receives your email or phone call, they believe you, but that doesn’t mean much unless they can either recover the money or convict those responsible. Both of these possibilities require evidence. To get that evidence, the federal government will need your help. This is for several reasons.

First, the federal government may not have the ability to get the evidence. The Fourth Amendment that prevents the federal government from engaging in searches of private individuals or organizations unless the government can show it has probable cause to make the search and seize evidence. In most cases, an email or phone call from an anonymous whistleblower is not enough to create probable cause.

Second, even if the federal government could investigate the alleged fraud further, it won’t, because it wants to avoid tipping off the people committing the fraud. If the government isn’t careful, the people committing the fraud could destroy evidence or flee to a non-extradition country if they get a whiff of a fraud investigation.

Still Looking at Becoming a Medicaid Fraud Whistleblower?

Click to find out more about being a Medicaid fraud whistleblower by contacting Bothwell Law Group online.

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.

Why Would I Need a Medicare Fraud Attorney?

Medicare Fraud Attorney

Medicare Fraud AttorneyIf you’re considering reporting Medicare fraud or have been the victim of retaliation for blowing the whistle, you may want to consider talking to a Medicare fraud attorney. Whistleblower laws are complex. In order to receive protection, you have to have reported an actual violation. The Medicare laws are complex. Without a strong background in Medicare law, even an experienced attorney may struggle to properly evaluate whether Medicare fraud occurred.

What Does a Medicare Fraud Attorney Do in a Whistleblower Case?

A Medicare fraud attorney’s job is to help you determine whether a Medicare violation occurred. If you are considering blowing the whistle, you may need help to prove that a violation occurred. The Medicare system is complex. Therefore, it is easy to feel that something is not quite right when a company is actually in full compliance with the law. Speak to a Medicare fraud attorney about the situation to find out whether an actual violation occurred. They can help you avoid a situation where you lose your job because of a mistaken fraud report. It’s important to know what whistleblower laws protect – and what they do not protect. Because of attorney-client confidentiality rules, you can almost always ask your own attorney for advice. That’s true even if you have a nondisclosure or confidentiality agreement with your employer.

Have you already made a report? Your employer will likely do everything they can to prove that no violation occurred. They will likely call on an experienced legal team who will work hard to find every possible defense and loophole. If they succeed, you may lose whistleblower protections. Working with your own experienced attorney can help. This way, you can ensure your claims are evaluated on their merits and not by your employer being able to outmaneuver you legally.

How a Medicare Fraud Claim is Evaluated

Medicare fraud typically involves some sort of false statement by a company. They may over-bill for services rendered or bill for services they never rendered. They may also engage in price-fixing. Finally, they may follow other non-competitive practices while claiming to operate under fair and open practices that give patients the best rates possible under market conditions.

When a fraud allegation is made, they will typically produce the falsified records as proof that everything was done properly. The key to proving a fraud claim is understanding how to exploit weaknesses in these documents. Furthermore, success depends on knowing how to use the available legal procedures to secure additional evidence that undermines the validity of these documents. This can be a monumental task for a layperson, especially if you are simultaneously fighting for your livelihood.

To schedule a consultation with an experienced Medicare fraud attorney, contact Bothwell Law Group today.

How to Report Suspected Fraud and Be a Medicaid Fraud Whistleblower

Medicaid fraud whistleblower

Medicaid fraud whistleblowerIf you have knowledge of fraud being committed by an organization that receives Medicaid funds, you may have grounds to become a Medicaid fraud whistleblower. Medicaid provides healthcare benefits to qualifying households from government funds. In order to become a Medicaid recipient, you must fall within certain income guidelines, having no health insurance or inadequate insurance for your medical needs.

What are the ins and outs of becoming a Medicaid fraud whistleblower?

Hospitals, physicians, pharmaceutical companies, or medical suppliers may commit Medicaid fraud. When a healthcare organization falsely conveys information to Medicaid, resulting in receiving additional compensation, this is considered to be Medicaid fraud.

Have reason to suspect your employer or your provider of Medicaid fraud?

You can become a Medicaid fraud whistleblower. One way to report suspected fraud is to make a complaint by calling the Attorney General’s Medicaid Investigations Division in your state. When you make the call, you will need to provide the following information:

  • First, the client’s name and Medicaid identification information.
  • Also, the name of the healthcare provider you are reporting.
  • Details concerning the service performed.
  • Finally, any evidence you have that fraud was committed.

Is this the easiest and safest way to report Medicaid fraud?

Calling a hotline concerning suspected fraud may seem like the easiest and safest way to report Medicaid fraud. However, there are downsides to making this choice. The False Claims Act entitles whistleblowers to up to 25 percent of the government funds recovered. The requirements for obtaining these funds have created a very involved process, one most whistleblowers are unable to navigate themselves. Don’t have an experienced Medicaid fraud attorney? You could miss out on the reward available to you for filing complaint against a healthcare organization committing Medicaid fraud.

When you hire an attorney who is knowledgeable of the process of filing a False Claims Act lawsuit, they will walk hand-in-hand with you through the process of becoming a Medicaid fraud whistleblower. Together with your attorney, you can take the steps that will increase your chances of a successful case and obtaining a portion of the recovered funds.

Can an attorney help you protect yourself from retaliation?

The False Claims Act clearly outlines the legal aspects of protection for whistleblowers. However, this statute can be difficult to navigate without proper representation. Having the right assistance and guidance will provide you with peace of mind as you move forward.

If you feel you have grounds for reporting suspected fraud and becoming a Medicaid fraud whistleblower, you need a qualified attorney on your side. You can learn more about Medicaid fraud and becoming a Medicaid fraud whistleblower. Most of all, call 770.643.1606 to contact one of our team members at Bothwell Law Group.

How Are Medicare Whistleblower Rewards Paid?

How Are Medicare Whistleblower Rewards Paid

How Are Medicare Whistleblower Rewards PaidAre you looking for answers regarding how Medicare whistleblower rewards are paid? The truth is Medicare whistleblowers can wind up with a very lucrative payout. By seeking qualified representation for whistleblower law and Qui Tam Law cases, a whistleblower’s potential for a payout from the liable parties can be substantial.

What Is the Whistleblower Law?

The whistleblower law is part of the False Claims Act, which was created in 1863 to crack down on Civil War profiteering. The False Claims Act was revamped and amended by Congress in 1989, making it more accessible and rewarding for any citizen to report false claims against the government. In essence, the law provides both reward and protection from retribution for someone who reports a validated fraud against the government or against public interest.

Whistleblowers, those who speak up about illegal practices affecting government agencies and other industries, have often been silenced by various forms of retribution including job loss, promotion freezes, blacklisting, and many other damaging practices.

The whistleblower law encourages citizens to come forward and inform the government of such fraudulent acts by protecting them from these consequences. The addition of the Qui Tam Law extends these rights by allowing the whistleblower to be rewarded financially, based on the amount recovered by the government in the court action.

How Does Qui Tam Work?

The Qui Tam Law allows an individual, known as a relator, to bring a lawsuit based on claims against the False Claims Act. The citizen, with a lawyer who is knowledgeable about the False Claims Act, brings the evidence to the court and asks the court to investigate the claim.

A relator is someone who has first-hand knowledge about the fraud. They will have access to documents to prove the claim. A Qui Tam claim is kept under seal, confidential, for at least 60 days, initially, although it is not uncommon for the court to extend this time. During the investigation, the entire matter is kept secret. The individual(s) being investigated are not made aware of the allegations or the inquiry.

Evidence in these cases can include things like shipping reports, invoices, bidding information, profit information among many other types of documents. The evidence must be first-hand, direct knowledge, supported by documents. If the court decides there is ample evidence to proceed, they will intervene, and they will then prosecute the case.

You remain a party to the case and cannot be dismissed or removed from the case without a hearing. If the government does not intervene, you can continue the case without them, through your whistleblower representation lawyer. It is much harder to win without the government intervention, but if you do, the reward is higher.

How Are Medicare Whistleblowers Paid?

The relator- whistleblower- is paid via a system determined by the False Claims Act. It begins with the court determining the amount of the penalties owed by the provider or practice. As a part of the lawsuit, the number of violations is added up. The letter of the law states that every single line of billing that is fraudulent is a separate violation, even if there are 25 on a single form. However, many courts have determined that each form is a violation, even if there are 25 separate entries. Once the number of violations is clear, the formula comes into play.

For each count, there is a penalty of between $5,500 and $11,000. Also, the amount of money the government was defrauded is refunded times three. When you consider that a winning case in court probably has hundreds or thousands of claims, the penalties can add up to tens of millions or even hundreds of millions of dollars in some cases.

The relator- the whistleblower- is awarded from 15-30% of the money recovered by the government. The potential for a very large reward is clear. It is not unusual for whistleblowers to receive rewards in the millions of dollars on large, high profile claims.

Some of the highest payouts ever made to whistleblowers include Medicare fraud. In 1999, Whistleblower George Courto, who worked for Bayer, filed a Qui Tam action against his employer and GlaxoSmithKline for selling relabeled drugs to an HMO on the cheap and not reporting the information to avoid paying millions of dollars in rebates to Medicaid. The total payout came to $344 million dollars and $34 million went to the estate of the whistleblower. In another Medicare case, GlaxoSmithKline paid out $333 million in penalties. The whistleblower here received over $53 million.

If you work for any provider that bills to Medicare and you are concerned about fraud issues, you should talk to an attorney who can help. The best way to know if an actual crime is being committed, and to keep yourself protected in the event of a blame-game, is to speak with an attorney who deals exclusively with whistleblower Qui Tam cases.  Have questions about how Medicare whistleblowers are paid? Click to contact the Bothwell Law Group online.

How Common Are Whistleblower Medicare Fraud Cases?

Medicare Fraud Cases

Medicare Fraud CasesYou might have heard about a few Medicare fraud cases here and there, but you probably don’t realize how big the problem is. Did you know Medicare and Medicaid fraud costs taxpayers billions of dollars every single year? Or, that an estimated 10% of Medicare and Medicaid claims filed are fraudulent? It’s true. And in the current economic climate, our government hardly has billions to spare.

This is what makes whistleblowing so powerful, and why the government continues to offer rich payouts to individuals who file qui tam lawsuits. As the primary remedy for fraud and false claims, they offer as much as 30% of the amount recovered to the party who filed suit. As you’ll see below, this can end up being quite lucrative under the right circumstance.

History: Medicare Fraud Cases in 2013

At the time, 2013 was a banner year for fraud recoveries. Efforts netted over $3 billion for the federal government, of which over 85% was related to health care fraud. These cases netted significant dollars for the state as well: $443 million went directly back to Medicaid as a result of these recoveries.

Most of the fraud pertained to drugs and medical devices covered under federally insured health programs specifically focused on the improper promotion of drugs for uses not tested and approved by the FDA. Abbot Laboratories, Inc. paid $1.5 billion to resolve allegations against a dementia drug, with $800 million being comprised of federal and state civil recoveries.

History: Medicare Fraud Cases in 2014

In 2014, over seven hundred whistleblower lawsuits were filed on behalf of the government. This was also the first year in which recoveries exceeded $5 billion (it was $5.69 billion, to be exact). Of this amount, $2.3 billion was related to federal health programs like Medicare and Medicaid; the fifth straight year the department netted more than $2 billion in this arena.

Johnson & Johnson, along with its subsidiaries, paid $1.1 billion to settle claims of off-label prescription marketing. Omnicare came in a distant second, paying $116 million to resolve allegations of an illegal kickback scheme.

History: Medicare Fraud Cases in 2015

While much less than 2014, the Justice Department still clocked a cool $3.5 billion as a result of judgments in civil cases pertaining to false claims. This was also the fourth year in a row that Justice beat the $3 billion mark. Since the tightening of legislation back in 2009, a grand total of $26.4 billion has been recovered under the False Claims Act.

Nearly two-thirds of the recovered monies in 2015 were a result of claims related to federal health care fraud. There were a few large settlements, but nothing as large as previous years:

  • DaVita paid $450 million to settle claims it generated unnecessary waste and billed the government for costs that could have been avoided.
  • DaVita also spent $350 million to settle claims it paid kickbacks to physicians in exchange for positive clinic referrals.
  • 500 different hospitals settled for $330 million after allegedly implanting cardiac devices in Medicare patients, contrary to the established rules and regulations.

Wondering If You’ve Got a Medicare Fraud Case?

Still have questions about Medicare fraud cases? Call 770.643.1606  to contact the Bothwell Law Group online.

Top 5 Reasons the Medicare Whistleblower Hotline Is Called

Medicare Whistleblower Hotline

Medicare Whistleblower HotlineIn an attempt to simplify and encourage more citizens to blow the whistle on Medicare fraud, Medicare whistleblower hotlines have been set up throughout the country. The purpose of a Medicare whistleblower hotline is to provide an easy and anonymous way for employees to report evidence of suspected illegal activity within their workplace.

There are various reasons why an employee may call a Medicare whistleblower hotline, but there are some reasons that are more common than others. Continue reading for the top 5 reasons the Medicare whistleblower hotline is called:

#1. Billing for a service that was not provided.

A healthcare provider may be routinely billing for procedures, most commonly diagnostic tests, that they have not provided to a patient. When the patient receives the incorrect statement, they typically call their provider first instead of Medicare that allows for this type of fraud to go unnoticed.

#2. Billing for supplies that were not provided.

Similarly to the scenario above, some providers may routinely bill Medicare for a supply under the false pretense that they have supplied it to a patient.

#3. Up-coding to be reimbursed at a higher rate.

Some healthcare providers may make a habit of up-coding, or billing a service as a higher paid procedure or test that was not performed. As an employee, reporting this type of fraud is incredibly important since an estimated 2% of Medicare claims are audited for up-coding.

#4. Misrepresenting a diagnosis or procedure.

If a procedure is not covered under Medicare, some healthcare providers will code it inaccurately to obtain reimbursement for that service. Additionally, since Medicare can only cover services that have been deemed as absolutely medically necessary, some healthcare providers will misrepresent a diagnosis as a way to obtain reimbursement for a service that would not be covered under normal circumstances.

#5. Billing bundled services individually.

There are multiple services, especially surgical or diagnostic services, that are bundled together to be billed as one service. In some cases, providers are unbundling these services and billing them separately across several bills as a way to receive additional compensation for a service provided.

The desire to submit an anonymous tip concerning Medicare fraud is completely understandable as many employees fear retaliation at the hands of their employer. However, there are laws in place that protect whistleblowers from retaliation. Although an anonymous call to a Medicare whistleblower hotline is helpful, lawsuits presented with evidence of fraud are more highly prioritized by the government and anonymous whistleblowers cannot be rewarded if the defendant is found liable.

Bothwell Law can assist you in filing a Medicare False Claims lawsuit and teach you what you need to know to protect yourself from retaliation. Find out what you need to know about the Medicare whistleblower hotline by clicking this link or calling 770.643.1606.

Medicare Fraud Whistleblower: What Are the Rules?

Medicare Fraud Whistleblower

Medicare Fraud WhistleblowerIf you know of Medicare Fraud, you may have occasion to be a Medicare Fraud Whistleblower. It’s important to know what the rules are.

One such whistleblower, Jacqueline Bloink, initiated a legal action resulting in a $35 million settlement to the federal government. Bloink is a former employee of the Carondelet Health Network and provided evidence of them submitting false claims to Medicare.

As a result, Medicare Fraud Whistleblower, Jacqueline Bloink, earned nearly $6 million.

What is considered Medicare Fraud?

  • Knowingly submitting false statements or misrepresenting facts to get federal health care payment when an entitlement would not exist otherwise;
  • Knowingly paying, soliciting, and/or accepting remuneration to reward or induce referrals for services or items reimbursed by Federal health care programs;
  • Making prohibited referrals for certain designated health services.

Obviously, defrauding the Federal government is illegal. Criminal and civil remedies for committing Medicare fraud include:

  • Fines
  • Imprisonment
  • Penalties
  • Exclusion from participation in Federal health care programs
  • Loss of professional licenses

5 Laws Governing Medicare Fraud:

  • United States Criminal Code
  • Anti-Kickback Statue (AKS)
  • False Claims Act (FCA)
  • Physician Self-Referral Law (Stark Law)
  • Social Security Act

5 Conditions That Must Be Met according to Medicare.gov:

  1. You report your suspected Medicare fraud. The allegation must be specific, not general.
  2. The suspected Medicare fraud you report must be confirmed as potential fraud by the Program Safeguard Contractor, the Zone Program Integrity Contractor, or the Medicare Drug Integrity Contractor (the Medicare contractors responsible for investigating potential fraud and abuse) and formally referred as part of a case by one of the contractors to the Office of Inspector General for further investigation.
  3. You aren’t an “excluded individual.”

Example

For example, you didn’t participate in the fraud offense being reported. Or, there isn’t another reward that you qualify for under another government program.

  1. The person or organization you’re reporting isn’t already under investigation by law enforcement.
  2. Your report leads directly to the recovery of at least $100 of Medicare money.

For more information about the Medicare Fraud Whistleblower Rules, have a confidential consultation with an experienced Whistleblower Attorney. They can help you navigate the tricky waters of a whistleblower law suit and help protect your rights. It’s important to know the rules, know your rights, know the laws surrounding Medicare and whistleblowing, and know the process inside and out.

$202 Million GA Medicare Fraud Case Starts Aug 3

False Claims Act | SEC Whistleblower Claim

Another Medicare Fraud Case under the False Claims Act

The Department of Justice (DOJ) intends to prove AseraCare is liable under the False Claims Act “because it caused non-terminally ill patients to prematurely give up curative or rehabilitative care so that the company could bill Medicare for hospice payments” according to DOJ attorneys.

A court document from the DOJ attorneys stated “In short, the United States’ told U.S. District Court Judge Karon Bowdre in one court document. “To the contrary, the United States brought this case based on evidence that AseraCare marginalized doctors, systematically pressured its own clinical staff to admit and keep ineligible patients, submitted false hospice claims for patients who were not terminally ill, and was put on notice from internal and external audits and employee complaints that this was occurring.”

Trial Date Set for August 3

A federal judge in Birmingham set a trial date of August 3 for this lawsuit which began when half a dozen AseraCare employees in Georgia, Alabama and Wisconsin filed whistleblower cases.

According to Patrick Burns, co-director of the Washington nonprofit Taxpayers Against Fraud Educational Fund, “It will be, far and away, the biggest hospice (FCA) case.”

Why $202 Million?

The DOJ analyzed random samples of 2,181 AseraCare patients for whom the company billed Medicare for at least 365 consecutive days of hospice care.  Patients were with AseraCare for two periods: Jan. 1, 2007 and Dec. 31, 2008 and between Jan. 1, 2009 and Feb. 28, 2011.

The findings: The DOJ argued more than half of the 233 cases should have been deemed ineligible for hospice care.

“Having a few patients who live longer than six months is expected”, Burns said.  “That should be one in a hundred, not fifty percent,” he said.

DOJ claims Medicare suffered nearly $67.5 million in damages due to the False Claims Act violations. According to the DOJ’s motion, if the jury awards the $67.5 million, then the judge is obligated under the law to treble the actual damages and award the U.S. a total of $202,481,144.

Congress created the Medicare hospice benefit in 1982. According to court documents, Roughly 90 percent of hospice patients are now covered by Medicare and/or Medicaid.

We will keep you posted on the events of this case. The law firm for the whistleblowers in this case is Frohsin & Barger LLC.

If you know of any Medicare or Medicaid fraud, contact a Whistleblower Attorney today!

 

 

AstraZeneca and Cephalon Pay $54 Million

Two False Claims Act cases have settled, resulting in $54 million in payouts.

Quarterly Rebates to Medicaid

Pursuant to the Medicaid Drug Rebate Program, each quarter, drug manufacturers are required to pay rebates to state Medicaid programs. This is in exchange for Medicaid’s coverage of the manufacturers’ drugs.

These quarterly rebates are based partly on the Average Manufacturer Prices (AMPs) the manufacturers report to the government per each covered drug.  It follows that the higher the AMP for a given drug, the higher the rebate state Medicaid programs get from the manufacturer.

Underreporting AMP’s

Both AstraZeneca and Cephalon allegedly underreported AMPs for several of their drugs. They did so by improperly reducing the reported AMPs for service fees they paid to wholesalers.

By underpaying quarterly rebates to state Medicaid programs, federal officials say  it caused the United States to be overcharged for its payments to states for the Medicaid program.

Millions in Settlement Payouts

AstraZeneca will have to pay $46.5 million, plus interest. This settlement resolves the allegations it knowingly underpaid rebates owed through the Medicaid Drug Rebate Program.

$26.7 million of that, plus interest, will be going to the United States. The remaining $19.8 million will go to the states participating in the settlement.

Similarly, Cephalon will be paying $7.5 million, along with interest, to settle similar allegations. $4.3 million of the settlement will go to the United States and the remaining $3.2 million will be divided among the states participating in the settlement.

These two settlements partially resolve a lawsuit filed under the whistleblower, or qui tam, provisions of the False Claims Act. This act permits private individuals to sue on behalf of the government for false claims. It also allows them to share any recovery.

 

 

Historical Amount of Medicare Fraud Arrests

Despite the historical number of Medicare fraud arrests, more are set to come. 

According to Modern Healthcare reporter Lisa Schencker, “Federal officials announced Thursday the largest coordinated, criminal Medicare fraud takedown—and the first large-scale effort to focus on Medicare Part D fraud—in the history of the U.S. Justice Department.

Over the last three days, the Medicare Fraud Strike Force has unveiled charges against 243 individuals across the country accused of falsely billing $712 million to Medicare in a number of separate schemes, said U.S. Attorney General Loretta Lynch. Those charged include 46 doctors, nurses and other licensed medical professionals.”

Of those arrested, more than 44 have been charged with fraud related to Medicare’s drug benefit program – Medicare Part D.

HHS Inspector General Daniel Levinson said costs in Medicare Part D reached $121 billion last year. “Our focus on Medicare Part D continues because more than 41 million Americans depend on that program, and its integrity must be protected,” Levinson said.

Law firms, like Health Law Partners, are starting to see a lot of fraud enforcement in the pharmacy area.

Medicare Part D More Difficult to Prosecute

Since Medicare Part D payments are capitated, instead of being fee-for-service, prosecuting in this area can be more difficult to prosecute than other areas of Medicade, according to Patrick Burns, co-director of the Taxpayers Against Fraud Education Fund.

Tony Maida, a former deputy chief of the administrative and civil remedies branch of HHS’ Office of Inspector General, also noted in a statement that the announcement Thursday “was packaged together by the government to create a high level of media and public exposure, as well as for a deterrent effect.”

Types of Charges Against the 243 Individuals

In this latest federal effort to crack down on fraud, the 243 individuals accused were charged with a variety of crimes including “conspiracy to commit healthcare fraud, violating the anti-kickback statute, money laundering and aggravated identity theft in areas including home healthcare, psychotherapy, physical and occupational therapy, durable medical equipment and pharmacy fraud.”

Who’s Investigating These Cases?

Medicare Strike Force teams from the Fraud Section of the Justice Department’s Criminal Division as well as U.S. attorney’s offices around the country are prosecuting and investigating these cases.

If you are aware of Medicare fraud, contact a Medicare Fraud Attorney as soon as possible.