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

Georgia Cracking Down on Medicare and Medicaid Fraud

$520,000 False Claims Act settlement is second this week.

The state of Georgia is cracking down on Medicare and Medicaid fraud.

If there’s any doubt on that score, just look at the two False Claims Act settlements that came out this week – a $20 million settlement with the Medical Center of Central Georgia in Macon, and a $520,000 settlement with Irwin County Hospital in Ocilla.

Mike Bothwell of the Bothwell Law Group in Atlanta, who helped settle the second case in less than 20 months, notes that heath care fraud cases can be complex, but that the law provides real rewards for whistleblowers who step up with insider information that leads to recoveries and an end to fraud schemes.

In his Irwin County Hospital case, won with the help of co‐counsel Brandon Hornsby at the Hornsby Law Group in Atlanta, the whistleblowers walked away with a $130,000 award for helping stop the fraud, and as compensation for the retaliation that followed.

Federal and State False Claims Acts allow private citizens with insider knowledge of fraud, waste, and abuse to bring an action on behalf of the governments in order to stop the fraud. If the case is won, the government can recover over three times the amount defrauded, and successful whistleblowers can receive between 15 and 30 percent of the governments’ recovery.

“It’s all about incentivizing integrity,” says Bothwell. “Chiselers are always incentivized to cheat. The False Claims Act sets things right by providing a countervailing incentive to do the right thing.”

There’s no question the False Claims Act works. Last year, the U.S. government and the states recovered well over $6 billion thanks to whistleblower‐initiated cases.

Bothwell notes that a lot of False Claims Act cases involve health care – a situation likely to continue as the Affordable Care Act kicks in.

The Macon hospital settlement involved allegation of upcoding for more expensive inpatient services when the billing should have been for less costly outpatient or observation services.

In the Irwin County Hospital case, the allegations involved kickbacks for patient referrals and for billing for improperly performed imaging services.

Bothwell notes that it looks like a real fraud‐fighting partnership is forming between Georgia Attorney General Sam Olen’s Medicaid Fraud Control Unit, the U.S. Department of Justice, and Georgia whistleblowers and their attorneys.

“We’re seeing a real public/private partnership that is bringing a real dividend for the American people. That’s exactly how the law is supposed to work.” Mike Bothwell, Whistleblower Attorney


About the Bothwell Law Group:

Since 1996, the Bothwell Law Group has earned a national reputation for successful representation of whistleblowers in federal and state courts across the United States, and is one of only a handful of firms exclusively representing whistleblowers. Bothwell Law Group’s cases have resulted in the recovery of more than $400 million for the United States treasury and in the payment of millions of dollars in whistleblower rewards. Inquiries may be directed to Mike Bothwell at (770) 643‐1606, email

For more information about the firm, FCA settlements and FCA experience, see


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.



Civil Division

Press Release Number:

20-649 & 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. & Mike Bothwell Lawfirm does not claim or imply ownership of this article. 

Full article link here:

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

To contact the editors responsible for this story: Jo-el J. Meyer at; Patrick L. Gregory at & Mike Bothwell Lawfirm does not claim or imply ownership of this article. Full article link here:

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.

What Is a Qui Tam Medicare Lawsuit?

Understand the importance of a qui tam Medicare lawsuit.

Qui Tam Medicare LawsuitDo you know what constitutes a qui tam Medicare lawsuit? Medicare is a government-funded healthcare plan. It provides eligible citizens with affordable healthcare options. The system relies on honest workers and a reliable healthcare system to make sure it operates smoothly. However, not all healthcare workers play by the rules. And, if they defraud Medicare, they should expect to get caught and pay the price.

The Role of Private Citizens in a Qui Tam Lawsuit

Qui tam comes from a longer Latin phrase meaning, “as the king as well as himself.” This type of lawsuit allows citizens to pursue legal action on behalf of the government. Today, the majority of these lawsuits fall under the False Claims Act. The government passed this legislation to encourage citizens to come forward with information.

The term relator applies to those citizens who bring forth a qui tam lawsuit or whistleblowers. In the world of Medicaid fraud, whistleblowers play an important role in exposing and stopping criminal activity.

Common Types of Medicare Fraud

Those receiving care from a hospital, nursing home, or hospice should pay close attention to what goes on around them. Many reported Medicare fraud cases directly affect patients. Doctors may “over-diagnose” a patient to get a kickback from Medicare. Some healthcare works will even change a patient’s prescription to another drug for unethical reasons.

Patients may notice inconsistencies with their healthcare provider, but few report them. Many of the whistleblowers are actually employees. Here are some of the most common types of Medicare fraud reported:

  • Overcharging for procedures or charging for procedures never administered
  • Partially filling medications but billing for the full dosage
  • Raising prices for Medicare patients
  • Ordering unnecessary tests
  • Changing diagnostic codes
  • Falsifying a patient’s records to justify more costly treatments

Medicare fraud is very dangerous. It can significantly affect the quality of life for patients. This is especially true if the doctor prescribes drugs or treatments that are not medically necessary. Too many patients, however, don’t recognize the warning signs of fraud. Patients trust their doctors and healthcare workers to provide them with honest service. Unfortunately, Medicare fraud is more common than people realize. Some estimates report Medicare fraud affecting between 8% and 10% of claims.

Protections Provided to Relators with the False Claims Act

Speaking up about wrongdoings is the right thing to do, but many people are afraid to come forward. Those committing Medicaid fraud don’t want to get caught. The legal ramifications for cheating the government are very harsh. Guilty parties may find themselves serving time or paying a hefty fine.

When someone blows the whistle on Medicaid fraud, they’re putting themselves at risk. Those running the scheme may try to silence them. However, the False Claims Act helps to protect whistleblowers from retaliation. It makes it illegal to threaten, harass, suspend, or fire a relator. It’s important to note that each state imposes its own statute of limitations.

Money Awarded to Whistleblowers with the False Claims Act

Whistleblowers can expect to receive something in return for their help. Under the False Claims Act, they receive a percentage of the money the government is able to recover. Most of these awards fall between 15-30 percent of the settlement.

Depending on the size of the case, this can be a large amount of money. The total amount is also dependent on whether the government intervened in the case. It’s not uncommon for a whistleblower to receive millions of dollars for their help in cracking a Medicare fraud scheme.

With the risk of retaliation so high, even with protections in place, the monetary award is the only reason some relators speak up. Thanks to whistleblowers, the Department of Justice was able to recover over $2.5 billion in 2018. Without private citizens reporting tips, the majority of fraud cases would still go unnoticed.

The Role of a Lawyer in a Qui Tam Lawsuit

If you have information about possible Medicare fraud, the government wants you to report it to the Office of the Inspector General. While you may want to let everyone know, it’s best to keep it to yourself. You never know who you may upset in the process, and for your safety, you should stay anonymous for as long as possible.

Before reporting your tip, however, be sure to consult with a lawyer who handles whistleblower lawsuits. Your lawyer will do everything possible to protect your identity and make sure you get your full settlement. Never try to represent yourself. Contact the skilled qui tam Medicare attorneys at Bothwell Law Group by calling 770.643.1606 today.

How Common Are False Claims by Medicare Providers?  

False claims by Medicare providers are more common and varied than most people think.

false claims by medicare providersCan you imagine the impact false claims by Medicare providers could have? Medicare is often the difference between a patient being able to receive health care and having to do without. In spite of the good it does for so many, there are those who attempt to game the system. That includes false claims by Medicare providers. How prevalent are these claims? It happens more often than most people realize.

Facts and Figures for Recent Years

Since the advent of the 1863 Federal False Claims Act, whistleblowers have come forth to stop specific incidents of fraud. While the majority of fraud once included fraudulent claims by suppliers and contractors, falsified Medicare claims increased significantly by the 1990s.

According to figures prepared by the US Department of Justice and released through the Department of Public Affairs, lawsuits filed between 1986 and 2018 recovered more than $59 billion. Much of that figure had to do with claims made by providers reported by whistleblowers and subsequently triggered lawsuits.  

During 2018 alone, 767 lawsuits related to provisions in the FCA began moving through the court system. Of that number, whistleblowers initiated 645 lawsuits. This continues the pattern that emerged over the last decade of new FCA cases having to do with alleged cases of false Medicare claims.

How Do They Do It?

There’s more than one way to go about falsifying Medicare claims. Providers who engage in this type of activity are likely to try one or more of the following:

  • Billing for services never performed: This may involve patients who often seek medical care and would not notice receiving one more claim report.
  • Billing for services that were unnecessary: Padding the claim with procedures or services the patient does not need is likely to draw even less attention from the patient.
  • Upcoding: Instead of billing for services rendered, the provider bills for similar services that are more costly and not merited given the patient’s current state of health.
  • Prescribing medications that the patient doesn’t need: The motivation here could be a kickback from a manufacturer in exchange for increasing the demand for a particular drug or classes of drugs.

These are only some of the more common approaches to creating false Medicare claims. Depending on the amount of effort put into creating documentation to back up the claim data, the fraud may be hard to detect even during a medical audit.

Signs Indicating an Altered or Completely False Claim

The fact that a false claim can be difficult to spot does not mean it’s impossible. A few signs could indicate all is not on the level. Knowing those signs makes it easier to determine if someone is the victim of a provider.

You may find that provider statements and receipts don’t match the details on the claim reports issued by Medicare. For example, you receive a claim report for services rendered on a date when you were out of town. That’s a sign something is wrong.

Even if the dates are right, the treatment received is not the treatment listed on the claim report. This can be more difficult for patients to spot if they are not familiar with the name of the treatments. It’s often helpful to compare any statements received from the provider with the detail on the claim report.

Perhaps the date is correct and the description of the treatment matches. What is different is the expense filed with Medicare. It happens to be more than initially quoted.

Any of these scenarios could be honest mistakes. The changes could also be intentional. If you talk with the provider and get a feeling that there’s something other than a clerical error involved, it’s time to take action.

What Can You Do About False Claims by Medicare Providers?

Protect yourself by keeping a log of all your medically-related appointments. That includes trips to the pharmacy to fill prescriptions. This allows you to cross-reference dates, treatments, and even events like annual physicals.

If you believe the activity is not an isolated event and the provider makes no effort to correct the problem, consulting with an attorney is a smart move. The attorney can help you assemble the necessary data and prepare to take legal action, including contacting Medicare and providing information about what you believe is taking place.

Do you suspect that a Medicare claim is fraudulent? Call 770.643.1606 to speak with one of the skilled lawyers at Bothwell Law Group today. If there is evidence of false claims by a Medicare provider, we’ll use every legal means to get to the truth.

What Happens in Medicare Qui Tam Cases?

Learn more about the process for Medicare qui tam cases.

Medicare Qui Tam CasesPrivate individuals use Medicare qui tam cases to show that a person or group has committed fraud against the government. The term “qui tam” is from a Latin phrase. It refers to someone who pursues legal action on behalf of the government as well as themselves. It originated in 13th century England, where it has since fallen into disuse. However, the United States still uses qui tam writs under the False Claims Act and a few other more specific laws. Cases of fraud against the government are the most common types of qui tam cases, especially in Medicare and defense contracting.

Qui Tam Overview

A private individual files a qui tam lawsuit on behalf of the federal government, usually under the False Claims Act. This individual, also known as a relator, is the plaintiff in a qui tam suit. People often refer to these suits informally as “whistleblower” suits. However, this term is overly broad, as the U.S. has other whistleblower laws besides the False Claims Act.

History of Whistleblower Law

The U.S. Congress originally enacted the False Claims Act during the Civil War. This legislation was in response to widespread fraud by government contractors against the Union Army. Congress removed many of the incentives for whistleblowers to come forward in World War II.

Congress restored these incentives in 1986, and the number of qui tam suits has multiplied since then. Lobbyists for the healthcare and defense industries have often attempted to weaken the False Claims Act since 1986. However, these efforts have generally been unsuccessful. The U.S. government has recovered about $40 billion since the 1986 reforms. Whistleblowers have received over $4.2 billion of this total.

Qualifying Acts

The False Claims Act generally covers false claims in federally funded contracts and programs. These programs include Medicare and Medicaid. Specific acts include submitting false claims for payment or causing the submission of those claims. They also include making false statements to get fraudulent claims paid. The concealment of records of fraudulent claims is another violation of the False Claims Act. Additional acts that can result in a qui tam suit include conspiring to defraud the government.

The most common type of false claim is one for products or services the claimant never provided. It also includes payment claims that violate contract, regulations, and statutes. Each false claim may constitute a separate violation of the False Claims Act. This provision means that qui tam suits often charge the defendant with a large number of violations.

The deadline for filing a qui tam suit under the False Claims Act is the greater of the following:

  • Six years after the violation
  • Three years after the government should have known about the violation

In no event can a relator file suit more than 10 years after the violation.

Defendant Liability

The defendant in a qui tam suit is potentially liable for three times the value of damages to the government. The defendant is also subject to civil penalties for each false claim. These can include invoices, demands for payment and other payment documents. These penalties can range from $5,500 to $11,000 for each claim. Many specific documents can form the basis for a qui tam suit, depending on the industry. The forms for Medicare cases include the following:

  • Medicare enrollment forms
  • CMS Form 1500
  • Form UB-92
  • Cost report forms
  • New drug and abbreviated new drug applications
  • Pharmaceutical pricing reports

Pharmaceutical pricing reports include ASP data forms and Medicaid rebate quarterly reports.

Relator Compensation in Medicare Qui Tam Cases

A person must file a qui tam suit to be eligible for compensation under the False Claims Act. It isn’t enough to just inform the government about a false claim. Furthermore, the government must recover money as a result of the suit before the relator can receive compensation.

A relator should receive between 15 and 30 percent of what the government recovers. This range applies whether the case results in a settlement or favorable verdict. The exact amount primarily depends on the significance of the roles that the relator and government play in the case. A more significant contribution by the relator increases the compensation. A more significant contribution from the government decreases the compensation.

The relator’s compensation is generally between 15 and 25 percent of the recovered damages if the government joins the lawsuit. If the government doesn’t intervene, the relator should receive between 25 and 30 percent of the recovery. Each relator gets a portion of the total compensation in qui tam cases involving multiple relators. The individual contribution of the relator determines the portion each individual receives.

If you are aware of fraud, you have protection in Medicare qui tam cases under the False Claims Act. Contact the skilled attorneys at Bothwell Law Group by calling 770.643.1606 today.

How to Protect Yourself as a Medicare Whistleblower

Is it dangerous to be a Medicare whistleblower?

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

Medicare Fraud Does Not Happen by Accident

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

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

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

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

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

Protection for Whistleblowers Depend on How You Complain

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

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

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

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

False Claims Cases Are Not Get-Rich-Quick Schemes

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

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

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

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

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

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

medicare billing fraud

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

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

Why Medicare Billing Fraud Cases Are So Common

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

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

Treatments Can Trigger Investigations

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

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

Hospice Isn’t Safe, Either

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

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

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

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

Putting a Stop to Medicare Fraud

Who can help stop medical billing fraud?

  • Patients
  • Family members
  • Healthcare workers
  • Office staff

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

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

How Qui Tam Lawsuits Stop Fraud and Boost Your Bank Account

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

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

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

What Do Medicare Fraud Attorneys Do with False Claims Reports?

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

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

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

Why People Should Care about Government Related Fraud

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

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

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

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

Suing a Fraudulent Medicare Provider

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

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

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

The Healthcare Industry

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

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

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

The Impact of Fraudulent FCA Filings

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

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

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

How Do Fraudulent Insurance Claims Affect Medicare?

Fraudulent insurance claims rob needy people of adequate healthcare.

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

Common Types of Fraudulent Claims

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

The most common types of insurance fraud include:

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

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

Billing for the Wrong Services or Those Never Provided

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

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

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

Changing the Date of Appointments on Medical Bills

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

Providing Unnecessary Services to Justify Additional Charges

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

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

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

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

Billing the Wrong Patient

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

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

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