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

How to Report Suspected Fraud and Be a Medicaid Fraud Whistleblower

Medicaid fraud whistleblower

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

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

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

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

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

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

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

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

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

Can an attorney help you protect yourself from retaliation?

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

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

Differences between Fraud and Mistake Under the US False Claims Act

US False Claims Act

US False Claims ActBefore filing a lawsuit under the US False Claims Act, some whistle blowers may be concerned about the legitimacy of their case. Maybe you feel unsure about the evidence you have gathered. Or, maybe you feel confused about the exact definition of fraudulent activity. At Bothwell Law Group, we hope to help you better understand the details concerning the US False Claims Act. It is a very detailed and complicated law. Before moving forward, we will clearly distinguish between fraud and a mistake.

What Is a Mistake?

In some cases, business owners may not be unethical or malicious. They may simply be terrible business owners. It is true that in some cases mistakes may result in the government losing money. However, we should be clear: a mistake is not the same as fraud.

How Is a Mistake Different from Fraud?

To put it simply, fraud requires knowledge of the consequences of your actions. Under Section 3729b of the US False Claims Act, the law is very clear. In order for fraud to occur the person must have knowledge of the laws regarding their actions, whether or not they are intentionally defrauding the government. Even if the purpose of their actions is not fraud, if they are aware of the laws regarding their choices, their actions will still be considered fraud.

If you are thinking the difference between a mistake and fraud under the false claims act seems to be a very fine line, you are right. For employees, who typically do not have professional experience with whistle blowing, it can be hard to distinguish between the two.

What Should You Do If You Suspect Fraud?

Because of this, we instruct any employee working in healthcare who suspects their employer may be committing fraud to gather any available evidence concerning their employer’s behavior. Next, we recommend employees who suspect fraud to play it safe by speaking with an attorney who has extensive experience working with Medicare fraud related lawsuits and who has thorough knowledge of the US False Claims Act.

An experienced false claims attorney can take a careful look at the evidence you have gathered. Then, they can make a suggestion about whether or not you should move forward with your claim. At Bothwell Law, our attorneys understand what it takes to have a successful Medicare Fraud lawsuit. We would never recommend moving forward if we did not believe you had adequate evidence of fraud.

Why You Should Get an Attorney

Working with an experienced attorney with experience in fraud can provide you with peace of mind and confidence, so if you are ready to move forward you can do so without worry. If we have determined you have substantial evidence of fraud, we will guide you through each step of the process.

Have questions about the US False Claims Act? Click to contact the Bothwell Law Group online.

How Insurance Agents Identify Fraudulent Insurance Claims

fraudulent insurance claims

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

What Are Some Signs of Medicare Fraud?

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

Duplicate Billing

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

Separate Billing of Services Normally Billed as One

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

Billing for Services Never Received

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

Medicare ID Sharing

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

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

What Should You Do If You Suspect Fraudulent Insurance Claims?

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

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

How Is the Validity of a Qui Tam Case in Healthcare Determined?

Qui Tam Case in Healthcare

Qui Tam Case in HealthcareA qui tam case in healthcare is one of the fastest growing claims in the last few decades, even surpassing military claims. Healthcare qui tam claims generally stem from improper or false billing for services or procedures, ‘off-label’ usage of FDA approved medications, or use of someone else’s health information to claim benefits.

Qui Tam Healthcare Cases and Whistleblower Laws?

Like any other qui tam cases, healthcare claims are covered by whistleblower laws. In a qui tam case, a person can raise a complaint on behalf of the government against individuals or companies that are behaving fraudulently.  Once a suit is raised, the government can investigate the whistleblower’s claims and choose to join the suit; if the suit is successful, the whistleblower (or relator) may receive a reward of up to 25 percent of the funds recovered by the government in the suit.

To protect a whistleblower from retaliation by an employer or others named in the suit, qui tam laws provide up to double the damages, plus attorney fees, for any retaliatory actions taken against a whistleblower.

How Are Qui Tam Cases Verified?

A qui tam case is not as simple as seeing an attorney and signing an affidavit. There are a number of steps you need to fulfill in order to file a valid qui tam suit:

  • You need to have credible evidence of wrongdoing committed by an individual or a company. The evidence needs to show either harm to the government, violation of the securities and commodities laws, or harm to employees or the general public.
  • You need concrete evidence of wrongdoing. Documentary evidence, while not required, will vastly increase the chance of government interest.
  • You need original evidence that cannot be gleaned from other sources. Evidence taken from public sources like the internet, TV news, or pubic government records cannot be used in a whistleblower claim.
  • You need to file right away. Under the ‘first to file’ rule, a whistleblower cannot file a claim if another whistleblower has filed one using the same evidence.
  • You need to remember the statute of limitations. It varies depending on the industry, but can range from 30 days to 6 years after the violations.

Can you Fake a Qui Tam Claim?

As with any suit, there may be unscrupulous folks who try to bring false claims under the False Claims Act.  This usually happens in order to collect rewards under the qui tam provision. These false claims will not hold up under scrutiny, nor will the evidence bear them out. Be aware that you may also be liable for perjury should you lie under oath.

Have questions about a qui tam case in healthcare? Call the Bothwell Law Group at (770) 643-1606.

What Are Qui Tam Actions in Healthcare?

qui tam actions in healthcare

qui tam actions in healthcareQui tam actions in healthcare make up a significant portion of the qui tam lawsuits brought by private individuals. This shouldn’t be surprising given the staggering size of the healthcare industry in the United States and the government’s need for healthcare services. The armed forces, Medicare, Medicaid and the Affordable Healthcare Act are just a few of the major examples of qui tam actions in healthcare.

What Is a Qui Tam Legal Action?

A qui tam legal action is where a private individual, called the relator, sues on behalf of the government. In the United States, the qui tam action falls under the False Claims Act.

Under the False Claims Act, anyone who defrauds the federal government can be liable for hefty financial penalties. Since much of the fraud against the government goes undetected, the enforcement of the False Claims Act relies heavily on whistleblowers to alert the government to the fraud and provide critical information as to what’s going on, who’s doing it, how long it’s been going on, etc. Almost three-quarters of all False Claims Act enforcement lawsuits are the result of a whistleblower first bringing the lawsuit through a qui tam legal action. If it weren’t for these whistleblowers, much of the money recovered by the federal government would not be possible.

Healthcare Spending by the United States Government

A qui tam lawsuit will work with healthcare company violators just as it would if the violator was any other company or government contractor. However, qui tam actions in healthcare are particularly notable for one reason: significant amounts of money are at stake.

There is a lot of money in the healthcare industry in the United States. One of the largest expenditures of the US government is paying for medical care of its citizens. For example, about 4% of the United States entire GDP (Gross Domestic Product) goes to Medicare and Medicaid programs. The GDP of the United States was about $18 trillion dollars in 2015. This means that in the Medicare and Medicaid programs alone, the federal government is spending hundreds of billions of dollars each year. That provides plenty of opportunities for unsavory companies and individuals to try and cheat the system and defraud the federal government. And we haven’t even discussed healthcare services for the military, the Affordable Care Act and Social Security benefits.

Qui Tam Actions in Healthcare

Another way that qui tam actions in healthcare are notable is because of the potentially high amounts of recovery that are possible under the False Claims Act. Punishment of a violator will consist of two components.

The first component deals with actual damages suffered by the federal government. The False Claims Act violator will pay three times the amount of actual damages. For instance, if a hospital overcharges the government by $1 million, it would have to pay $3 million in damages.

The second component deals with penalties for each false claim submitted to the government. Currently, each claim carries a penalty of anywhere between roughly $11,000 and $22,000. This amount can also go up each year as a result of inflation. When healthcare fraud occurs, it usually occurs many times.

Looking at the earlier example of a hospital overcharging the federal government $1 million of medical care, let’s further assume that the $1 million involved the treatment of 10,000 patients. This amounts to 10,000 instances of fraud against the federal government. Since each instance of fraud is subject to between $11,000 and $22,000 in penalties, the hospital may face anywhere from $110 million to $220 million in penalties. This is on top of the $3 million it must pay in damages.

Even though the fraud amounted to “only” $1 million or $100 per patient, the hospital must now pay at least $113 million in penalties and damages for its False Claims Act violations. Since the qui tam provisions of the False Claims Act allow relators to recover anywhere from 15% to 25% of the amount ultimately recovered by the federal government, relators have the potential to receive a very substantial reward. In certain instances, this reward can be as low as 10% or as high as 30%. Looking at the hospital hypothetical, a relator could potentially recovery anywhere from $11 million to $66 million.

But before you decide to go on a whistleblowing crusade to get this type of reward, understand that these rewards are relatively rare and may take many years to obtain. On the other hand, understand that this hypothetical isn’t too far-fetched, either.

Many of the largest False Claims Act recoveries have been in the healthcare industry. Take for instance the top 20 largest pharmaceutical company legal settlements in the United States, which ranged from $345 million to $3 billion – only two of them did not involve the False Claims Act.

Do You Have Questions about a Qui Tam Lawsuit In Healthcare?

Qui tam actions in healthcare can be quite complicated with all of the money at stake. If you think you may want to report healthcare fraud against the federal government, learn more by contacting the Bothwell Law Group.

When to Report Fraud When You Are Aware of Fraud

when to report fraud

when to report fraudWhen to report fraud is a question you may be facing if you are aware of it happening but aren’t directly involved. If you don’t report it, will you be in trouble? There are a lot of unknowns in the world of whistleblowing and fraud. It’s time to dig into it for some insight and to give you direction and peace of mind.

What Do You Mean Report Fraud?

Fraud in this context refers to businesses that fraudulently take money from the US government in a variety of different ways, including Medicare fraud, criminal defense contract fraud, and nursing home fraud, to name just a few of the most common scenarios. There are many different ways people charge government programs for goods and services that are either not delivered or not justified.

Because fraud exists on such a broad level, laws have been created to encourage private citizens to report fraud when they witness it. These rules are known as False Claim Act laws, and they date back to the days of Abe Lincoln and the Civil War. Because people aren’t prone to report things that could cause them a backlash, the False Claims Act includes provisions for the whistleblower to receive a portion of any money recovered in a lawsuit. There are also laws to protect the whistleblower from losing their job.

Some of these laws and protections directly address just when and how we need to report fraud once we know about it. Surprisingly, there is not one simple, easy to understand rule. The law varies according to different industries, and it even changes from state to state.

The important thing to remember is if you are aware of fraud, you are likely obligated to report it, or else you may be found guilty of defrauding the government as well.

When Do I Need to Step Forward and Report Fraud?

Most people who report fraud are employees of the company committing the fraud. For example, one of the most common areas of fraud is within the program of Medicare. If you work in a doctor’s office as a nurse and never touch the bookwork, you probably have no idea the fraud is taking place. If you transfer to the accounting department, however, you may begin to see a problem.

Even if a person is involved in the actual fraudulent activities, they can still be the reporting whistleblower. The law does stipulate that fraudulent charges in Medicare cases need to be brought within 30 days of discovery of the practice. If a person is aware of the fraud and fails to report, they are in danger of prosecution under the law. However, even though the law allows for the prosecution, it rarely actually happens.

Even if a business or individual self-reports their participation in the fraud, they are not exempt from possible prosecution. Often, however, a judge will levy a lower penalty upon a voluntary disclosure of the activity.

How Do Your Report Fraud to the Government?

Fraud is reported with a complaint made in District Court. The best practice for any whistleblower is to hire an attorney familiar with the False Claims Act. Choosing an attorney who works exclusively in this type of law is always the wisest decision.

Because there are so many ins and outs regarding the statutes of limitations, as well as different kinds of both penalties and protections for whistleblowers, it is critical to hire an attorney who understands all of the particulars of this area of law. The attorney will verify the facts in the case and prepare the complaint on behalf of the whistleblower.

Once the paperwork is brought to a district court, it is put under seal, prohibiting anyone, including the whistleblower, from breaking that seal by disclosing anything. The seal protects the identity of the whistleblower at this stage of the process. In fact, the defendant doesn’t even know an investigation exists. The original seal on the case is for six months. This timeframe is almost always extended, giving the government many months or even years to perform their investigations.

Once the inquiry is complete, the government makes a decision whether or not they will intervene, or take over, in the case. If the federal government does decide to step in, they take over the prosecution of the case. The court serves the defendant notice, and quite often a settlement is reached without actually going to court

If You Are Aware of Fraud, Report It to a Whistleblower Attorney

If you are aware of fraudulent billing practices taking place at your place of work, or any organization for that matter, contact an attorney who works in False Claims Act law right away. Even if you are knowingly participating in the illegal activity, you should retain an attorney and file the complaint.

If you are not actively involved and the court determines proof of fraud, you are entitled to between 15% and 25% of the monies recovered. The amount of that reward can reach millions of dollars in some cases. Have questions about when to report fraud? Contact the Bothwell Law Group online now.

What Does a Health Care Qui Tam Attorney Need to Prove a Case?

health care qui tam attorney

health care qui tam attorneyA health care qui tam attorney needs a case that involves a direct party—usually an employee or former employee—bringing a case of fraud against the government. It’s a case filed under the False Claims Act, which was developed to protect the government against fraud. Many circumstances leading to fraud involve

Medicare or Medicaid, both of which are federally regulated programs to pay for medical services. Health care qui tam cases can also include nursing home fraud, pharmaceutical fraud, medical device fraud, hospice or home health fraud and healthcare scams.

Here are a few examples of health care fraud activities that might be involved:

  • Billing for services not provided
  • Billing for more expensive services than the ones performed
  • Delivering more expensive services than were medically needed
  • Misrepresenting the diagnosis to justify payment
  • Creating false documentation to support payment
  • Billing under the provider number of a different doctor than the one who performed the procedure
  • Performing medical procedures without a physician supervising
  • Backdating procedures for a time the patient was insured
  • Kickbacks and Stark Law violations
  • Billing for “overflow” of medicine
  • Off-label marketing of pharmaceuticals

You may wonder if the information you have is enough to file a health care qui tam case. While every case is individual, knowing the basics of what an attorney needs to prove a case could help you determine if you’re heading in the right direction.

It’s like packing for the family summer vacation. If you leave everything to memory and guesswork, you’ll likely forget something important. If you make a list of all the essentials, you stand a much better chance of getting to where you’re going with everything you need. You know that will save you time- and probably a whole lot of hassle and expense than if you just pack off the cuff.

Here are some things your health care qui tam attorney needs to prove a case:

Your Health Care Qui Tam Attorney Needs to Know the Timeframe

One of the first things to knock off your qui tam case checklist is when the fraudulent activities took place. There is a statute of limitations of six years in false claims acts. Some circumstances fall outside this boundary, but your attorney needs to know when the fraud took place.

Documentation of dates can be one of the most powerful pieces of evidence in a health care qui tam case. This record will serve to prove the timeframe is within the statute of limitations.

Your Health Care Qui Tam Attorney Needs to Have Credible Information of Fraud

You may be aware of fraudulent activity at your place of employment due to your expertise and experience. Your health care qui tam attorney will talk with you about the information you are aware of and help determine if it is credible enough to provide the basis of a case. This information may be verbal, or you may have physical evidence. Physical evidence is tricky and can be difficult to obtain. Talk with an attorney who is knowledgeable about false claim act suits and he or she will be able to determine the credibility of what you know.

When you meet with your health care qui tam attorney, bring any proof you have as evidence of the fraudulent act. Your evidence can include things like receipts, copies of fraudulent paperwork or bookwork and other items that may be in your possession. Your attorney will have a staff to investigate and gather evidence and will assist you in determining if that evidence is sufficient for a qui tam case.

Your Health Care Qui Tam Attorney Needs to Determine If You Are an Original Source

Only one person can bring a particular qui tam case. If the fraud has already come to the attention of the government, you cannot bring a separate case. Your attorney will research and find out if you are the original source of the alleged fraud. Your information comes from inside information, if you are the primary source, not from something you read about or heard about somewhere else.

Your Health Care Qui Tam Attorney Needs Knowledge to Prove a Case

It’s important to choose an attorney who knows qui tam law in the health care field. The details matter in any lawsuit and with qui tam cases there are an awful lot of rules and regulations governing every aspect of the process. Also, if the government chooses not to intervene, you need an attorney with the wisdom to know if you should proceed on your own or not. Choose an attorney who has successfully argued health care qui tam cases in the past, so you can trust he or she will make solid decisions.

Learn more about the benefits of using a health care qui tam attorney by contacting the Bothwell Law Group online.

Medicare False Claims Act Penalties: Who Actually Pays?

Medicare False Claims Act Penalties

Medicare False Claims Act PenaltiesWho pays when it comes to Medicare False Claims Act penalties? There are laws in place that require real penalties and pay rewards to citizens who report the fraud as well. The False Claims Act penalties exist to recover some of the billions of dollars fraudulently taken annually.

What Medicare False Claims Act Penalties Are There?

Unfortunately, Medicare is the pot of gold for several different types of fraudulent acts that carry strict penalties under the False Claims Act. There are blatant and continual scams being perpetrated. Under the Qui Tam Law, the person who brings these criminal acts to court can also be compensated if the government receives restitution from the case. Some of these include:

  • Billing Medicare for services that were not provided
  • Billing Medicare for services that were not medically necessary.
  • Billing Medicare for services at a standard of care/certification that was not provided to the patient
  • Kickbacks given for referrals of patients in Medicare
  • Self-referral for Medicare patients

Medicare False Claims Act Penalties: How Does This Happen?

One of the largest types of crimes with penalties under the False Claims Act is billing Medicare for services that are never actually provided. Many times this is as simple as it sounds—submitting charges for services no one performs. Often, the deception is done so overtly that the patient files have nothing to back up the charge—no orders, no notation of the patient having been seen, or no follow up. When these cases are prosecuted, they are relatively easy to prove, although direct testimony from patients is needed.

Other fraudulent billing practices include coding issues. Each medical procedure has a code that someone enters into a form for billing purposes. Often an incorrect code is entered, leading to billing for a higher cost service. Human error accounts for some mistakes, of course, but a pattern of errors points to fraud.

Many services are bundled together and given a code as a group. Another type of coding error involves unbundling these services and placing individual charges, which can be significantly higher.

Another fraud consists of bills submitted to Medicare for services that are not medically necessary, such as unnecessary tests, imaging, or equipment.

Some providers will bill Medicare for services at a higher level of care than a patient received. This violation can include charging a specialist fee without the patient consulting with a specialist or charging for an M.D. when a nurse practitioner or physician’s assistant provided the services.

Kickbacks are a widely known type of fraud in the healthcare industry. Kickbacks concerning Medicare include providers who accept payment or reward in return for soliciting Medicare recipients. Many cases involve a health care provider receiving a financial incentive for purchasing special equipment and then billing Medicare for that equipment without revealing the kickback.

Self-referrals are when a doctor refers a patient to a practice in which the doctor is an invested owner. A doctor cannot be financially benefitting from a referral. A referral is done to get a client the best health care, not to increase one’s coffers.

So, Who Actually Pays for Medicare False Claims Act Penalties?

When a fraudulent claim is brought to court and successfully prosecuted, there are penalties to be paid. The penalties are based on the number of counts of fraud, the amount of money recovered, as well as up to three times the programs’ losses.

Every single charge, every single kickback, every single misrepresentation is considered a claim. It’s easy to see how the number of claims can add up quickly. The penalty for each claim is assessed on the amount of damages to the government—in other words, the amount of money Medicare paid out for the fraudulent claims. The liable party must pay three times the amount of these costs. Also, there is a penalty assessed between $5,500 and $11,000, for each claim.

The claim is paid by the person or business found liable for the fraud by the court. It should come as no surprise to anyone that there are insurance policies available to healthcare professionals to help defray these costs. Insurance can be obtained to cover both the defense and the penalties in False Claims Act claims.

If someone is notified of False Claims Act charges, they should immediately tender notice to their insurance provider. If the provider does not tender notice as soon as possible, they are potentially forfeiting their coverage and protection.

If you are looking for more information about False Claims Act penalties and how the Qui Tam Law benefits the person who brings this type of fraud to court, call (770) 643-1606 to learn more by contacting Bothwell Law Group online.

What Is the Process for Reporting Medicare Fraud?

Reporting Medicare Fraud

Reporting Medicare FraudIndividuals reporting Medicare fraud is one of the government’s only lines of defense. The system is so vast; it’s impossible to police every transaction. And as a result, they enacted the False Claims Act, designed to incentivize individuals aware of potential fraud to come forward. The law has morphed slightly over time, becoming more stringent, and with a particular focus on medical billing and practices.

One of the most common types of medical billing fraud is something called up-coding: billing the government for a process, procedure or medicine which costs more than what was administered. Let’s use up-coding as an example to explain how fraud happens, and process for reporting it.

How Up-Coding Happens Without Being Caught

The coding system itself is electronic, with a set of universal codes for every medical charge. Doctors and hospitals submit bills through insurance and the coding system, then on to Medicare. Because of the high number of transactions, Medicare audits less than 2% of the total volume. It’s a system practically begging to be abused!

Now do you see why the government must rely on individual citizens to help identify and report Medicare fraud?

What to Do When You Suspect Medical Claim Fraud

The first thing you need to do is gather proof and information. Any form of emails, letters, voicemails, alternate records, patient files and so forth are critical for reporting fraud. Once you have the information, you can best decide how to proceed next.

When to File a Qui Tam Lawsuit

If the fraud you discover is minimal, your best bet is to go through Medicare.gov or the Office of the Inspector General. Likewise, if you suspect the fraud to be significant in size, but can locate very little proof, these may be your best bets.

However, if the scale and size are significant, and your evidence is substantial, you may want to consider filing a qui tam lawsuit under the False Claims Act.

Why You Might File a Qui Tam Lawsuit

In addition to feeling like a good citizen, reporting fraud to your government and helping to recover taxpayer dollars, you also become eligible for a portion of the recovery amount. As much as 30% of the amount covered can be awarded to you as a result of bringing the case to the government’s attention. In large-scale fraud cases, the size of the pie can be larger than most lotteries.

Consult a Legal Professional about Fraud

Your first step the moment you discover a shred of evidence should be to talk to a lawyer specializing in filing suit under the False Claims Act. They can help guide you toward the best solution based on the particulars of your case.

What Not to Do If You Suspect Medical Claim Fraud

Don’t start telling everyone you know you suspect fraud may be occurring. This violates some specific requirements for filing a qui tam suit, specifically that the perpetrator not be made aware of it. The technical term is filing “under seal” and you nullify the opportunity by making your suspicions public… even if the “public” in question is only immediate friends and family.

Ready to Find Out More about Reporting Medicare Fraud?

Still have questions about reporting Medicare fraud? Contact our team at Bothwell Law Group, and we’ll help you get the answers you need to make your decision.

How Common Are Whistleblower Medicare Fraud Cases?

Medicare Fraud Cases

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

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

History: Medicare Fraud Cases in 2013

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

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

History: Medicare Fraud Cases in 2014

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

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

History: Medicare Fraud Cases in 2015

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

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

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

Wondering If You’ve Got a Medicare Fraud Case?

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

How Does Legal Representation Work in a Medicare Whistleblower Case?

Medicare Whistleblower Case

Medicare Whistleblower CaseIf you’re thinking of filing a Medicare whistleblower case, you’re not alone. Every year, billions of dollars (yes, that’s billions with a B) are spent on false medical claims. Whether the source is inadequate care, illegal kickbacks, or overcharging for goods and services, the scope of fraud is frankly astronomical. In fact, one government audit estimated as much as 10% of Medicare charges are fraudulent!Medicare Whistleblower Case

Common Types of Medicare Fraud

In case you are wondering what qualifies as “fraudulent,” here is a list of some of the most common forms you might come across in any medical practice:

  • Double Billing: Billing for the same service more than once.
  • Fake/Phantom Charges: Charging for services that were never performed.
  • Up Charging: Billing for expensive equipment and testing when inferior items were actually used.
  • Co-payment Comps: Rolling required co-pays into the bill under false charging categories.
  • Kickbacks: Receiving a benefit from a company or lab in exchange for using them exclusively, or more than others.

And the list goes on and on. Every year, people find new ways to attempt to defraud the Medicare program. The government must rely on good citizens to turn in the fraudsters, blowing the whistle on illegal activities. This is the heart of the False Claims Act.

Filing a Whistleblower Suit…Or Not

Once you become aware of any fraudulent activity against the government, the first thing you should do is stay quiet and hire a lawyer. Be sure to do some research, and interview a few firms. This is incredibly important as your lawyer will be a vital part of your success, and determining the size of reward you may be eligible to receive.

Once your attorney has reviewed the case, they can advise you on the best course of action. In some instances, it may be in your best interest NOT to file suit. Your lawyer should explain the possible outcomes, ramifications, and the likelihood of success so you can make an educated decision.

If you do decide to proceed, you will be filing as a private citizen acting in the interest of the government, to recover funds on their behalf. You may or may not need to cover attorney fees accumulated up to this point; be sure and ask about the billing and settlement process during the interview phase.

Government Review of Medicare Fraud Suits

Your lawsuit will be filed in secret (AKA “under seal”), and only you, your attorney, and the government will be aware it exists. The government has this opportunity to review all the facts, findings, and proof contained in your supporting documents. Based on the strength of the case, the government then chooses whether or not to join your case, or intervene.

Government Intervention for Whistleblower Lawsuits

If the government joins, they take over pursuit of the case, working with your lawyer to hand it off to their attorneys. This is a good thing, as cases where the government intervenes have a much higher success rate. Your payout is then determined at the end of the trial, and most of your attorney fees are likely covered through the payout.

If the government doesn’t intervene, then you have to choose whether to push forward or not. Your share of the payout will be higher if you succeed, but if the lawsuit fails, you may be liable for all your attorney fees.

Looking for More Information on Whistleblower Legal Representation?

Contact the skilled Medicare whistleblower case attorneys at Bothwell Law Group by calling 770.643.1606 today.

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

how to report healthcare fraud

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

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

How to Report Healthcare Fraud:  Gather Evidence

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

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

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

How to Report Fraud:  Understand Your Options

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

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

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

How to Report Fraud:  Consult a Qui Tam Lawyer

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

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

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

Anything Else You Need to Know about Healthcare Fraud Reporting?

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