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Universal Health Services, Inc. And Related Entities To Pay $122 Million To Settle False Claims Act

False claims act

Universal Health Services, Inc. And Related Entities To Pay $122 Million To Settle False Claims Act Allegations Relating To Medically Unnecessary Inpatient Behavioral Health Services And Illegal Kickbacks

Universal Health Services, Inc., UHS of Delaware, Inc.(together, UHS), and Turning Point Care Center, LLC (Turning Point), a UHS facility located in Moultrie, Georgia, have agreed to pay a combined total of $122 million to resolve alleged violations of the False Claims Act for billing for medically unnecessary inpatient behavioral health services, failing to provide adequate and appropriate services, and paying illegal inducements to federal healthcare beneficiaries, the Department of Justice announced today. UHS owns and provides management and administrative services to nearly 200 acute care inpatient psychiatric hospitals and residential psychiatric and behavioral treatment facilities nationwide. UHS is headquartered in King of Prussia, Pennsylvania.

As part of a comprehensive civil settlement, UHS will pay the United States and participating states a total of $117 million to resolve allegations that its hospitals and facilities knowingly submitted false claims for payment to the Medicare, Medicaid, TRICARE, Department of Veterans Affairs, and Federal Employee Health Benefit programs for inpatient behavioral health services that were not reasonable or medically necessary and/or failed to provide adequate and appropriate services for adults and children admitted to UHS facilities across the country.

In a separate civil settlement, Turning Point will pay the United States and the State of Georgia $5 million to resolve allegations that it provided free or discounted transportation services to induce Medicare and Medicaid beneficiaries to seek treatment at Turning Point’s inpatient detoxification and rehabilitation program or intensive outpatient program.

“The Department of Justice is committed to protecting patients and taxpayers by ensuring that the treatment provided to federal healthcare beneficiaries is reasonable, necessary, and free from illegal inducements,” said Acting Assistant Attorney General Ethan P. Davis for the Department of Justice’s Civil Division. “The Department will continue to be especially vigilant when vulnerable patient populations are involved, like those served by behavioral healthcare providers.”

The government alleged that, between January 2006, and December 2018, UHS’s facilities admitted federal healthcare beneficiaries who were not eligible for inpatient or residential treatment because their conditions did not require that level of care, while also failing to properly discharge appropriately admitted beneficiaries when they no longer required inpatient care. The government further alleged that UHS’s facilities billed for services not rendered, billed for improper and excessive lengths of stay, failed to provide adequate staffing, training, and/or supervision of staff, and improperly used physical and chemical restraints and seclusion. In addition, UHS’s facilities allegedly failed to develop and/or update individual assessments and treatment plans for patients, failed to provide adequate discharge planning, and failed to provide required individual and group therapy services in accordance with federal and state regulations.

Of the $117 million to be paid by UHS to resolve these claims, the federal government will receive a total of $88,124,761.27, and a total of $28,875,238.73 will be returned to individual states, which jointly fund state Medicaid programs.

“Quality mental health treatment is critical for the patients who place their trust in the hands of service providers,” said William M. McSwain, United States Attorney for the Eastern District of Pennsylvania. “The allegations involved in this matter — inappropriate billing and inadequate care – have no place in our health care system. Behavioral health service entities must have strong mechanisms in place, including appropriate supervision and oversight, to avoid fraud and abuse in order to ensure they provide the level of care that their patients deserve.”

With respect to Turning Point, the government alleged that, from January 2007 until May 1, 2019, the facility provided free or discounted transportation services to Medicare and Medicaid beneficiaries to induce them to seek detoxification and rehabilitation treatment at Turning Point’s inpatient or intensive outpatient programs.

“Illegal inducements should never play a role in a patient’s decision regarding treatment, especially when a patient is seeking care for addiction and other behavioral health needs,” said Byung J. “BJay” Pak, U.S. Attorney for the Northern District of Georgia. “Our office remains committed to pursuing unlawful arrangements that undermine the integrity of federal healthcare programs.”

The government’s settlement with UHS resolves 18 cases pending in the Eastern District of Pennsylvania, Western District of Michigan, the Eastern District of Michigan, and Northern District of Georgia under the qui tam, or whistleblower, provision of the False Claims Act, which permit private parties to file suit for false claims on behalf of the United States and to share in any recovery. The whistleblower share of the federal portion of the settlement will be $15,862,457.03. The settlement with Turning Point resolves an additional qui tam lawsuit filed in the Northern District of Georgia. The whistleblower in that suit will receive $861,853.64, from the federal share of the Turning Point settlement.

“Providing top quality health care to service members and their beneficiaries is the primary mission of the Defense Health Agency. It’s unfortunate a company tried to take advantage of a system that ensures health care for those men and women who are on the front lines every day protecting our nation,” said Lt. Gen. Ronald Place, director, DHA. “We commend the Department of Justice and its partners for bringing justice to those responsible for knowingly defrauding TRICARE beneficiaries.”

“VA OIG continues to be vigilant in holding those accountable who defraud VA programs and ensure that tax payer dollars are appropriately utilized for the care of our nation’s veterans and their dependents. Also, we thank our law enforcement partners and the United States Attorney’s Office for their support,” said Acting Special Agent in Charge Jeffrey Stachowiak, Department of Veterans Affairs, Office of Inspector General.

“The OPM OIG does not tolerate predatory behavior that risks the health and safety of vulnerable patients,” said Thomas W. South, Deputy Inspector General for Investigations for the Office of Personnel Management. “We are grateful for the fine work of our investigators and Department of Justice partners. Today’s settlement demonstrates OPM-OIG’s unwavering commitment to investigating conduct that affects vulnerable FEHBP enrollees.”

Contemporaneous with the civil settlements announced today, UHS, on behalf of its inpatient acute and residential behavioral health facilities, has entered into a Corporate Integrity Agreement with the U.S. Department of Health and Human Services, Office of Inspector General (OIG), which will remain in effect for five years. UHS must retain an independent monitor, selected by the OIG, which will assess UHS’s Behavioral Health Division’s patient care protections and report to the OIG. In addition, an independent review organization will perform annual reviews of UHS’s inpatient behavioral health claims to federal health care programs.

“Protecting the health and safety of Medicare and Medicaid patients is one of our primary concerns. Our Corporate Integrity Agreement provides future protection for patients and federal health care programs through controls and monitoring designed to ensure that UHS’s behavioral health facilities provide quality services and medically necessary care to patients,” said Gregory E. Demske, Chief Counsel to the Inspector General for the United States Department of Health and Human Services. “This case demonstrates that the government will aggressively pursue allegations of substandard inpatient care.”

The settlement with UHS was the result of a collaborative effort among numerous federal and state agencies. The Commercial Litigation Branch of the Department of Justice’s Civil Division and the U.S. Attorney’s Office for the Eastern District of Pennsylvania handled the cases, with substantial assistance from the U.S. Attorneys’ Offices for the Middle District of Florida, the Northern District of Georgia, the Eastern District of Michigan, the Western District of Michigan, the Middle District of Georgia, the Northern District of Illinois, the Middle District of North Carolina, the Western District of North Carolina, the District of Oregon, the Middle District of Pennsylvania, the Southern District of Texas, the District of Utah, the Eastern District of Virginia, the Western District of Virginia, the Northern District of Oklahoma, and the District of Wyoming, as well as the National Association of Medicaid Fraud Control Units (NAMFCU). The Civil Division and NAMFCU coordinated the nationwide investigation of UHS in partnership with the Office of Inspector General for the Department of Health and Human Services; the Department of Defense Criminal Investigative Service; the Department of Veterans Affairs, Office of Inspector General; the Office of Personnel Management, Office of Inspector General; and the Federal Bureau of Investigation. The Civil Division’s Commercial Litigation Branch and the U.S. Attorney’s Office for the Northern District of Georgia handled the Turning Point matter with assistance from the Office of Attorney General of Georgia and the Office of Inspector General for the U.S. Department of Health and Human Services.

The civil settlement with UHS resolved the following captioned cases: United States ex rel. Gardner v. Universal Health Services, Inc., 2:17-cv-03332-AB (E.D. Pa.); United States ex rel. Naylor v. Universal Health Services, Inc., 2:14-cv- 06198-AB (E.D. Pa.); United States ex rel. Jain v. Universal Health Services, Inc., et al., No. 2:13-cv-06499-AB (E.D. Pa.); United States ex rel. Chisholm v. Universal Health Services, Inc., et al., 2:17-cv-01892-AB (E.D. Pa.); United States ex rel. Doe, et al. v. Universal Health Services, Inc., et al., No. 2:14-cv-00921 (E.D. Pa.); United States ex rel. Pate v. Behavioral Hospital of Bellaire, et al., 2:15-cv-00554-AB (E.D. Pa.); United States ex rel. Brinson, et al. v. Universal Health Services, Inc., et al., 2:14-cv-07275-AB (E.D. Pa.); United States ex rel. Mitchell v. Turning Point Care Center, Inc., et al., 2:15-cv-00259-AB (E.D. Pa.); United States ex rel. Peterson v. Universal Health Services, Inc., et al., 2:17-cv-01897-AB (E.D. Pa.); United States ex rel. Conaway, et al. v. Universal Health Services, Inc., et al., 2:17-cv- 02233-AB (E.D. Pa.); United States ex rel. Eborall v. Universal Health Services, Inc., et al., 2:17-cv-03249-AB (E.D. Pa.); United States ex rel. Sachs, et al. v. Universal Health Services, Inc., et al., 2:17-cv-03604-AB (E.D. Pa.); United States ex rel. Klotz v. Universal Health Services, Inc., et al., 2:17-cv-05163-AB (E.D. Pa.); United States ex rel. Brockman, et al. v. Universal Health Services, Inc., et al., 2:17-cv-05350-AB (E.D. Pa.); United States ex rel. Glass v. Hughes Center, LLC., et al., 2:18-04018-AB (E.D. Pa.); United States ex rel. Parent-Leonard v. Forest View Psychiatric Hospital, et al., No. 1:18-cv-1426 (W.D. Mich.); United States ex rel. Russell, et al. v. Universal Healthcare Services, Inc., et al., No. 1:19-CV-0764 (N.D. Ga.); United States ex rel. McLauchlin, et al. v. Havenwyck Holdings, Inc., et al., No. 2:19-cv-10832 (E.D. Mich.).

The settlement with Turning Point resolved the case captioned United States ex rel. Heatley v Turning Point Care Center LLC, et al., 1:17-cv-3869-AT (N.D. Ga.).

The claims resolved by the settlements are allegations only, and there has been no determination of liability.

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Component(s):

Civil Division

Press Release Number:

20-649

Whistleblowerlaw.com & Mike Bothwell Lawfirm does not claim or imply ownership of this article. 

Hospice to pay $1.75 million to resolve false claims act allegations

The USDJ Northern District recently published the below. See a portion below: 

ATLANTA – STG Healthcare of Atlanta, Inc. (“STG Healthcare”) and two of its senior executives, Paschal “Pat” Gilley and Mathew Gilley, have agreed to pay $1.75 million to resolve allegations that STG Healthcare, operating as Interim Healthcare of Atlanta, submitted or caused the submission of false claims to Medicare and Medicaid for patients who were not eligible for the hospice benefit and that resulted from STG Healthcare’s provision of unlawful payments to a referring physician in violation of the Anti-Kickback Statutes.

“Hospice is not a blank check for unscrupulous medical providers willing to admit patients who are not terminally ill,” said U.S. Attorney Byung J. “BJay” Pak.  “It is reserved for those who truly need it.  We will also continue to prioritize cases where it appears that a medical decision, especially the decision to forego curative treatment, has been influenced by a kickback.”

“When healthcare providers put their financial interests above the needs of patients the federal funds are diverted from where they are truly needed, putting our most vulnerable citizens at risk,” said Chris Hacker, Special Agent in Charge of FBI Atlanta. “The message is clear; the FBI will not tolerate companies who file false claims to generate more corporate revenue and take advantage of programs like Medicare & Medicaid.”

“As more Americans choose hospice care, more government funding is being provided to this critical service. Unfortunately, scammers are seizing an opportunity to steal precious funding by enrolling ineligible patients in hospice care,” said Derrick Jackson, Special Agent in Charge for the Office of Inspector General of the U.S. Department of Health and Human Services.  “With our law enforcement partners, we will continue to protect patients and the programs on which they depend.”

“The hospice benefit provided by Medicaid is especially reserved for terminally ill Georgians at a critical time of transition in their care,” said Attorney General Chris Carr.  “Our office is proud to have worked alongside the U.S. Attorney’s Office for the Northern District of Georgia in this effort, and we will continue to ensure the hospice benefit is not exploited and abused by health care providers to the detriment of Georgia taxpayers.”

The Medicare and Medicaid hospice benefit is available for patients who elect palliative treatment (medical care focused on providing patients with relief from pain, symptoms, or stress) for terminal illness and who have a life expectancy of six months or less if their illness runs its normal course.  Before billing government healthcare programs, a hospice provider must comply with Medicare and Medicaid’s requirements and ensure that patients who are foregoing curative care are in need of end-of-life care.

Whistleblowerlaw.com & Mike Bothwell Lawfirm does not claim or imply ownership of this article. 

Full article link here: https://www.justice.gov/usao-ndga/pr/hospice-pay-175-million-resolve-false-claims-act-allegations

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.

Whistleblower in a Medicaid Fraud Case? Here’s What You Need to Know

Don’t blow the whistle until you know what to expect when you become a whistleblower in a Medicaid fraud case.

Whistleblower in a Medicaid Fraud CaseKnowing without a doubt that someone is doing wrong is enough reason to become a whistleblower in a Medicaid fraud case, right? In a perfect world, you would come forward with the information, and the guilty party gets sentenced. You become a hero, and everyone sings your praises. However, this is not always the case.

We do not live in a perfect, honest society. Medicaid fraud is rampant. The National Conference of State Legislatures reports that this type of fraud costs states billions of dollars per year. If you know something, the government wants you to speak up. But, becoming a whistleblower is not as simple as it may sound.

Here are the top things you should know before choosing to become a whistleblower:

Your Word Isn’t Always Enough Proof

Even if you know without a shadow of a doubt that someone is committing fraud, your word isn’t proof enough. To investigate further, authorities need more evidence. Sure, if you call and make a formal complaint, they will look deeper into the matter. That doesn’t mean, however, that they will ever collect enough evidence to make an arrest.

What makes it so difficult to gather evidence? The Fourth Amendment puts limits on how authorities can search and collect evidence. It protects citizens from unwarranted searches and seizures. To legally search a suspect’s property, the authorities must have probable cause. They must also obtain a warrant. Even if you know that someone is guilty, your word may not provide enough probable cause to further the investigation.

However, this doesn’t mean you shouldn’t make a complaint or report someone. If the fraud is blatant, your word may be all it takes to initiate the case. Authorities may have enough information from your testimony to open a case and convict the perpetrators.

You May Face Retaliation

Coming forward with information is the right thing to do, but it’s not always safe. Unfortunately, many whistleblowers become targets for retaliation. In many cases, these cases involve a network of individuals. It’s rare for only a single person to run a scam of this nature. If you stop their money-making venture, you may find yourself a victim of retaliation.

There are many different levels of retaliation. Some people may see you as a traitor and treat you differently at work or in private. It’s not uncommon for the accused party to fire, demote, suspend, or monetarily punish a whistleblower. A whistleblower may experience public shaming or harmful threats. Retaliation is illegal, but the law is not always correctly understood or enforced.

While the federal government offers protections to whistleblowers in many cases, these laws vary from state to state. Some states only protect whistleblowers in the public sector and not those who work for a private employer. A lawyer can help explain the different whistleblower laws for your area.

You May Receive a Large Cash Payout

The law allows whistleblowers to collect a considerable cash sum after settlement. This amount may vary, but it usually falls somewhere between 15-30 percent of the settlement figure. The percentage varies on the type and location of the case. For most whistleblowers, the possibility of receiving a cash payout is very enticing. And in many cases, it’s the only reason someone chooses to come forward.

However, be aware that the final settlement amount determines the amount you will receive. Many cases settle for much less than the initial complaint. You may not receive the compensation amount you initially expected. Weighing the pros and cons of a cash payout is important. For example, will you lose your job as a result of becoming a whistleblower? How long will the case last? You may find yourself waiting several years before the case finally closes.

You Need Legal Counsel

Whistleblowers have helped solve many Medicaid fraud cases. Authorities rely on others to provide information to help convict guilty parties. If you have information that could crack open a fraud case, you should consider alerting the proper authorities. But, before you do, it’s best to hire an attorney to represent you.

As a whistleblower in a Medicaid fraud case, you may find yourself in a stressful or dangerous situation. Others will try to stop you from talking. You may feel unsure of how to proceed. You need someone who knows the law and how to protect you. An attorney will guide you through the legal process. This will help you maintain your safety, privacy, and integrity throughout the entire case.

The legal team at Bothwell Law Group represents clients who are a whistleblower in a Medicaid fraud case. Whistleblowers run into resistance at every turn. A whistleblower lawyer will help you navigate these turbulent waters with ease. Contact the skilled Medicaid fraud whistleblower attorneys at Bothwell Law Group by calling 770.643.1606 today.

Four Facts about Medicaid Qui Tam Lawyers

What you should know about Medicaid qui tam lawyers before you blow the whistle.

medicaid qui tam lawyersIf you’re aware of Medicaid fraud, you need to know about Medicaid qui tam lawyers. Medicaid fraud is hard to execute and is often even harder to prove, which is why it’s vital to have a qualified lawyer on your side.

Do you have some concerns about reporting the fraud to the proper authorities? That’s common with whistleblowers. The good news is there are laws in place to protect you. Qui tam laws not only protect whistleblowers, but they also reward them, entitling informants to a part of the financial settlement. But that can’t happen without Medicaid qui tam lawyers. Here’s what you need to know.

Why Medicaid Matters

The Medicaid program is essential. It provides health care to millions of Americans, especially to those who are in need. Many low-income adults, pregnant women, children, seniors, and people with disabilities use Medicaid for their healthcare coverage. As of November 2018, Medicaid has over 66 million people enrolled. The bad news is that some people and organizations game the system to gain illegal access to Medicaid funds.

Medicaid fraud occurs when someone makes a misleading claim with the intent of receiving Medicaid funds. Most often done by health care providers, it can include billing Medicaid for more services than provided, overstating the cost of the services provided, exaggerating the supplies needed for medical care, and charging more than the reasonable value of service. While Medicaid fraud can appear obvious, it can be hard to prove in a court of law. Many companies that commit Medicaid fraud have been doing it for years and have it down to a science.

If you witness, are aware of or are suspicious of Medicaid fraud, it’s imperative that you do the right thing and report the fraud. Failing to do so means that some people who need health care might not receive treatment due to lack of funding. It also means letting the bad guys keep on doing what they’re doing.

Qui Tam Lawyers: What You Need to Know

If you’re considering reporting the fraud, it’s crucial to have a lawyer on your side. Here are four facts you need to know about Qui tam lawyers:

  1. They understand what you’re risking as a whistleblower. They know you’re trying to do right by the government, and they are there to support you. You may have seen other people try to do the right thing and report fraud, and then get punished for speaking up. Qui tam lawyers understand what you’re putting on the line when you make the choice to report. It’s likely that you’re concerned about your career and your reputation. You may also have concerns about how you’ll care for your family if you end up being out of work due to your reporting. The laws and the lawyers are here to protect you from repercussions related to whistleblowing.
  2. They know Medicaid laws inside and out. Federal health care laws contain complicated information, and many health care businesses use this to their advantage. It takes an experienced Medicaid attorney to find the details of illegal or fraudulent behavior. If you’re not sure if something is fraudulent, we’re here to help explain the laws to you. As with most things in life, if something seems off, it probably is.
  3. Medicaid lawyers have relationships with government officials. This allows them to work outside of court. This can mean the protection of your privacy. Many Medicaid qui tam cases settle out of court. Our relationships with government officials allow us to start working on your case immediately. One of the toughest parts of pursuing any court case is waiting. Weeks turn into months, and settlements can seemingly take an eternity to pay out. Relationships with officials allow lawyers to speed this process along, getting you the money you deserve faster than if you had to go through the court system.
  4. They do their research. Qui tam lawyers know that cases need to be bulletproof when going up against people who have no problem committing fraud. It’s vital that the facts and knowledge of health care law are substantial.

Don’t Go It Alone – Call a Pro

If you’re aware of Medicaid fraud, it’s important that you do the right thing and report. Failing to do so can mean misused funds that don’t go to Americans who need them. When you report, you need a qui tam lawyer on your side. Speaking up can be hard, and we’ll be by your side every step of the way. Choose Medicaid qui tam lawyers who know qui tam laws inside and out by contacting Bothwell Law Group.

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.