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Category: Medicaid Fraud

How Are Medicare Whistleblower Rewards Paid?

Posted on by Mike Bothwell
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?

Posted on by Mike Bothwell
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

Posted on by Mike Bothwell
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?

Posted on by Mike Bothwell
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

Posted on by Mike Bothwell
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

Posted on by Mike Bothwell

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

Posted on by Mike Bothwell

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.

 

Endangering Babies For Profit

Posted on by Mike Bothwell

Bottom line: Medicaid pays the same amount for a Midwife as for an Ob-Gyn. Thus, some hospitals have a financial incentive to push even the high-risk patients to use Midwives rather than doctors. Unfortunately, this is happening at considerable risk and sometimes serious damage to patients.

$100 Million Lawsuit Filed

$100 Million federal law suit was filed against Indiana University Health and 2 associated medical organizations, Healthnet and MDWise.  Allegations state “Contrary to their carefully crafted image of offering compassionate care for the indigent, two of the largest healthcare providers in Indianapolis put poor, pregnant women and their newborn babies at risk with a fraud scheme designed to increase revenues, regardless of the law or the risks to the most medically-fragile patients.”

A doctor at the hospital filed a complaint after what she saw there. Dr. Judy Robinson is the former medical director at the hospital. “I’m filing this lawsuit because of the abysmal care I witnessed these people receiving. And, after approaching IU Health, nobody would do anything.” Robinson pointed out that patients who should have received monitoring during their pregnancy didn’t receive the monitoring. “There was little to no physician involvement in the obstetrical care of these high-risk patients.”

Under the state Medicaid reimbursement rules, “Nurse midwives may not provide services to members with medically high-risk pregnancies. However, according to the lawsuit, lower-cost nurse midwives handled high-risk patients, in violation of the Medicaid regulations.

To make it worse, the hospital filed false-claims with the state and federal government for doctor services the patients never received. The hospitals are using midwives but getting reimbursed for using doctors.

Babies Permanently Damaged

According to Dr. Robinson, at least 3 babies suffered permanent neurological damage and 17 infants nearly missed a tragic outcome.

Watch the TV interview here. 

Thanks to whistleblowers like Dr. Judy Robinson, the lives of children may be dramatically changed for the better.

If you think you may have a whistleblower case, have a confidential talk with a whistleblower attorney as soon as possible. These are time-sensitive matters. A whistleblower attorney knows how to protect your rights and get results.

Children’s Hospital Pays Millions in Settlement

Posted on by Mike Bothwell

Hospitals around the country have been accused of violating the false claims act.  Children’s Hospital in D.C. is among them.

The allegations against Children’s Hospital

Children’s Hospital, Children’s National Medical Center Inc. and it’s affiliated entities, collectively known as CNMC faced claims of violating the False Claims Act. They are accused of submitting false claims reports and other applications to the Department of Health and Human Services (HHS) and to Medicaid programs in Virginia and the District of Columbia.

Violating False Claims Act Raises Health Care Costs for Everyone

“The false reporting alleged in today’s settlement deprived the Medicare Trust Fund of millions of taxpayers’ dollars,” said Principal Deputy Assistant Attorney General Benjamin C. Mizer of the Justice Department’s Civil Division.  “Such conduct wastes critical federal health care program funds and drives up the costs of health care for all of us.”
“The integrity of federal health care programs depends on honest and accurate reporting from the hospitals and other health care providers that receive hundreds of billions of tax dollars every year,” said Acting U.S. Attorney Vincent H. Cohen Jr. of the District of Columbia.  “This settlement demonstrates our commitment to defending the integrity of the system and ensuring that taxpayer money goes to meet the most critical health care needs.  We will continue to work with whistleblowers like the former employee who came forward in this case to battle waste, fraud and abuse that fuel the skyrocketing cost of health care.”

The settlement Agreement

Children’s Hospital agreed to pay $12.9 million in a settlement agreement. According to the settlement agreement, in two distinct ways, CNMC misstated information on cost reports and applications.  The HHS and Medicaid programs used the false information to calculate reimbursement rates to CNMC. The United States contended that CNMC falsely reported its available bed count on its application to HHS’ Health Resources and Services Administration under the Children’s Hospitals Graduation Medical Education (CHGME) Payment Program. This program provides federal funds to freestanding children’s hospitals to help maintain their graduate medical education programs. Such programs train pediatric and other residents.

The United States further contended that CNMC filed cost reports which misstated their overhead costs. These false reports resulted in overpayment from Medicare as well as the Virginia and District of Columbia Medicaid programs.

Allegations against CNMC were filed by James A. Roark Sr., a former employee of CNMC, under the qui tam or whistleblower provisions of the False Claims Act.  Under the False Claims Act, a private citizen can sue on behalf of the United States and share in any recovery. The United States is entitled to intervene in a False Claims Act lawsuit, as it did in this case.

From the $12.9 million settlement, Mr. Roark will receive $1,890,649.98.

Health Care Fraud Prevention and Enforcement Action Team (HEAT) Initiative

In May 2009, the Attorney General and the Secretary of Health and Human Services announced the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative. This was done in efforts to combat health care fraud. The two departments are working together to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of their most powerful tools is the False Claims Act.

$24.3 billion has been recovered through False Claims Act cases since January 2009. More than $15.3 billion involves fraud against federal health care programs.
Please note: This particular matter was handled by the U.S. Attorney’s Office of the District of Columbia with assistance from the Civil Division’s Commercial Litigation Branch and the HHS’ Office of Inspector General.
The case is United States ex rel. Roark v. Children’s Hosp., et al., No. 1:14-cv-00616 (D.D.C.).
The claims resolved by the settlement are allegations only, and there has been no determination of liability.

 

Pharmaceuticals Paying Doctors

Posted on by Mike Bothwell

Are Doctors Relying on Pharmaceutical Companies to Pay Their Salaries?

More and more evidence seems to indicate that pharmaceutical companies are funneling money into the pockets of doctors who regularly prescribe their medications. This makes many people wonder whether they really need the medications they take, or if they are helping their physicians pay for their cruises, homes, and fancy cars.

The Startling Figures

According to an analysis performed by Modern Healthcare using an Open Payments database regarding Medicare Part D information, some 400 doctors prescribed more than $1 million worth of drugs in Medicare’s Part D prescription program. Of those 400 doctors, 23% received some sort of financial kickback from the drug manufacturer, whether in the form of consulting fees or other perks. As an example, a neurologist in Saginaw, Michigan named Dr. Gavin Awerbuch billed Medicare for more than $6.4 million worth of Subsys, a drug designed to help cancer patients fight pain, in 2013. The Justice Department indicted him last year for the fraudulent prescription of unnecessary medications.

Other Guilty Parties

Dr. Awerbuch is not the only party guilty of receiving money for prescribing medications. Dr. Vallerie McLaughlin, a University of Michigan cardiologist, prescribed nearly $5 million worth of Tracleer to Medicare recipients in 2013. This made her the sixth-highest prescriber of a single drug. What’s more, the manufacturers of that drug, Actelion Pharmaceuticals, a Swiss company, paid her $40,491 that year in clinical consulting fees, meals, and travel. Is that merely a coincidence, or are physicians truly prescribing unnecessary medications just to line their pockets?

Is It Legal?

There is no law that prevents pharmaceutical companies from rewarding doctors who regularly prescribe their medications. However, the drug makers cannot simply write the physicians checks for a job well done. Instead, they pay “consultation fees” to the doctors, which is nothing more than a clever way for the physician to earn a handsome kickback simply for prescribing a popular medication. Often, these fees include things such as luxurious meals, travel accommodations, and more – and sometimes even for the physician’s family, too.

What Does This Mean for Medicare Recipients?

Does this mean that Medicare recipients should be wary of every single drug they are prescribed? In some cases, yes. Although there is no proof that doctors across the country continue to prescribe medications to people who do not need them just to get financial kickbacks, it is happening – and it has been proven in some cases. Medicare recipients who receive prescriptions should carefully question their physicians to determine whether the drug is truly necessary. What’s more, obtaining a second opinion is also an option. Patients should do their own research and assist in determining whether medications are helpful or not necessary at all.

It is certainly sad that physicians who swore oaths to “do no harm” would prescribe their patients to take potent medications, often with severe side effects and the potential for addiction, even when those drugs are not necessary, just to earn some extra cash. It means that consumers must be on their toes, questioning their healthcare teams in times of sickness and health alike.

Prescription Drug Costs Rising

Posted on by Mike Bothwell
False Claims Act | SEC Whistleblower Claim

The Truth behind Exorbitant Prescription Drug Costs

Pharmaceutical companies claim that the tremendous costs of prescription drugs are due to the sheer amount of research and development that goes into creating them. However, there is more to it than that. Pharmaceutical companies have one primary goal: maximizing the value of the company to shareholders. Often, maximizing that value equates to Americans paying exorbitant prices for their prescription medication – and some of these medications keep people alive.

How It Works

Big-name pharmaceutical companies across the globe are jacking up the prices of necessary prescription medications for no other reason than to increase revenue. While the pharmaceutical industry is like any other in that a little competition is healthy for the end users of the medications, many companies have taken things to extremes. A company may buy a medication that it sees as undervalued, then raise the price by 100%, 200% or even as much as 500%. Aside from this, companies put a high price tag on new treatments and regularly raise the prices of older medications, too. While the shareholders may be happy about these changes, the people who need their medications to stay alive are often swimming in debt.

Valeant Leads the Industry in Price Hikes

The Canada-based company known as Valeant is perhaps the key player in the industry price hikes. Since early 2011, the company has raised the prices on its medications by at least 20% some 122 times. More recently, on February 10 of this year, the company purchased the rights to a pair of life-saving heart medications known as Isuprel and Nitropress. The day following the acquisition, Isuprel’s price rose 525% from $215.46 to a jaw-dropping $1,346.62 for a one-milliliter vial. Nitropress jumped 212% from an original price of $257.80 to an astonishing $805.61 for a two-milliliter vial.

Other Companies Following Suit

Another prime example is the acquisition of Cadence Pharmaceuticals by Mallinckrodt PLC. Mallinckrodt purchased the company in order to gain the rights to Ofermev, a pain injection they believed was significantly undervalued. Three months later, the price of the already expensive injection jumped 2 ½ times to $1,019.52 for 24 doses. Horizon, another common pharmaceutical company, purchased the rights for a pain tablet known as Vimovo from the well-known AstraZeneca in 2013. Horizon sold Vimovo for the first time on Jan. 1, 2014 at a price 597% more than the original cost, which was $959.04 for 60 tablets.

Even generic drug prices are rising. Doxycycline, the most commonly used malaria treatment in the world today, has increased from an average price of $20 for 500 tablets to a whopping $1800 for the same amount. The drug is readily available in other countries for $40, which is a testament to corporate greed in the North American pharmaceutical industry. These prices not only take a huge toll on the average consumer, but they drive up the costs of health insurance programs, too.

 

 

Average Joe Jailed for Medicaid Fraud

Posted on by Mike Bothwell

In today’s day and age, federal and state governments work tirelessly to protect the funding for public services such as Medicaid and Medicare. In the past, while the governments focused their fraud watches on hospitals and healthcare providers, they now look at Medicaid recipients themselves, including Melissa Letica Simmons, a 49-year-old woman from Gadsden County, Florida.

The Average Joe vs. Corporate Fraud

Florida Attorney General Pam Bondi said that Simmons, a home healthcare worker in Gadsden County, one of the poorer counties in Florida, had defrauded taxpayers to the tune of $13,000. As such, Bondi played a role in sentencing Simmons to six months in jail. However, just a few years prior, the state accused three major hospitals of defrauding Medicaid to the tune of millions of dollars. There was no criminal prosecution of any of the parties involved, and the hospitals managed an insignificant punishment – they repaid the funds they stole from taxpayers for only pennies on the dollar.

The State’s “Amicable Settlement”

A Floridian fraud case involving many different hospitals resulted in a statement directly from the state, saying it wanted to “resolve this matter amicably with our industry partners.” Thus, a poor woman receives a six-month jail sentence for a $13,000 crime while several large hospitals receive little to no punishment because the state wants an amicable relationship. Prosecutors rarely want amicable resolutions; they want to see the criminal punished to the extent allowed by law.

How Florida Legislature Views Healthcare Fraud?

According to the aforementioned truths, Florida seems to view those who commit fraud alone as evildoing criminals with an intent to steal from taxpayers. However, when an entire corporation is in on the theft, even to the tune of millions of dollars, it is chalked up to clerical error or misunderstanding. Rather than jailing those responsible – or even forcing them to pay back what they stole – these hospitals and other companies settle for just pennies in order to keep their reputations intact. The judge in the corporate case claims that the men involved had “already been punished” with the damage to their reputations.

As it turns out, it would seem that Aesop was right all along. Sometimes, the government chooses to “hang the petty thieves and appoint the great ones to public office” for no other reason than to set an example. With legislators like this, corporations will only continue to commit fraud, while the little guy remains afraid of his own “clerical errors”.

If you need help with a whistleblower law suit, call an experienced whistleblower attorney right away!