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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.

What Are Some Typical Types of Whistleblower Medicare Fraud that Goes to Court?

whistleblower medicare fraud

whistleblower medicare fraudIf you work for, or have knowledge of, any company violating any laws or regulations pertaining to Medicare and Medicaid, you could be a whistleblower for Medicare fraud. And if these violations fall under the scope of the False Claims Act, you may have grounds for a lucrative qui tam lawsuit; up to 30% of monies recovered if the court finds in your favor.

While the money is certainly a great incentive, active participation and oversight from people most closely involved in the healthcare industry prevents billions of lost taxpayer dollars. In 2014 alone, the Justice Department recouped $6 billion in FCA claims, with nearly half that amount stemming from healthcare fraud.

What Constitutes Healthcare, Medicare, or Medicaid Fraud?

Many businesses and industries receive funds from the federal government both directly and indirectly. This includes hospitals, nursing homes, private physicians, pharmacies, laboratories, medical equipment providers, and many more. Any action that leads to receiving government money, or postponing payment to the government, for fraudulent reasons, is fair game. To make it easy for you, we’ve created a list of some of the most common occurrences:

  • Charging for a full prescription, but only partially filling it
  • Kickbacks to physicians and other medical providers in exchange for exclusively using certain products, or prescribing specific medications
  • Ordering tests that are not medically necessary
  • Prescribing drugs or treatment not medically necessary
  • Increasing billing prices solely for Medicare or Medicaid patients
  • Knowingly providing substandard or defective medical devices
  • Knowingly providing substandard medical services
  • Falsely diagnosing a more significant medical issue than the one a patient actually has in order to charge for more intense and expensive treatments (commonly called upcoding)
  • Changing a prescription to a more expensive treatment as a result of kickbacks
  • Falsifying drug research grant information and outcomes
  • Charging for treatments, prescriptions or services separately when they can be performed together at a reduced cost (sometimes called unbundling)
  • Steering individuals to a specific course of treatment, medicine, or medical company when you have a vested interest in company performance (commonly called self-referrals)
  • Double billing both the government and private insurance or the patient
  • Falsifying records to meet compliance standards (most common with medical devices and machines)
  • Submitting bills to Medicare that don’t apply under the Secondary Payer
  • Requesting reimbursement for costs related to non-Medicare patients
  • And more…

You can see from the list above the many ways different individuals and businesses can go about defrauding the government. It’s almost impossible to catch it all, which is why the government relies on whistleblowers. Ensuring there is a proper system in place for both the reporting of fraud, and protection of the individual making the claim is the reason the False Claims Act and qui tam provision exist today.

Filing a Qui Tam Lawsuit

If you think you may have knowledge of Medicare, Medicaid, or other healthcare fraud, you should contact a lawyer immediately. They’ll be able to tell you what the options are, and keep you from doing anything that may compromise the grounds for your case. Plus, they can help you gather the information you need to adequately support your lawsuit inside both the Justice Department and the courtroom.

Still have questions about being a whistleblower for Medicare fraud? Call 770.643.1606 to contact the Bothwell Law Group online.

What the False Claim Act for Healthcare Means to You

False Claim Act for Healthcare

False Claim Act for Healthcare The False Claim Act for healthcare is essentially a small component of a much larger set of regulations making it a crime to knowingly record or file a false claim, regarding any federal healthcare program. While Medicare and Medicaid are both considered federally funded programs, it also extends coverage to any plan or program providing health benefits (including through insurance) which receives any funding from the federal government or state-sponsored healthcare system.

Examples of fraud covered under the FCA include billing for services never received, double billing (billing for the same service more than once), or making any sort of false statement in an effort to obtain payment for services.

Penalties Associated with Falsifying Claims

Any violation discovered and prosecuted under the FCA carries stiff penalties. From a financial perspective, an individual or organization is on the hook for three times the amount of the falsified claim, plus an additional penalty of up to $11,000. These penalties are on a per claim basis, so in cases of systematic fraud, the dollars begin to add up quickly.

Violations can also be counted as a felony charge, and result in jail time, additional fines, or both. Anyone found to have received a benefit by way of fraud, made a fraudulent statement, or worked to conceal material facts can be held liable.

Protection for Individuals Reporting Fraud – aka – Whistleblowers

Any employee who reports a violation under the False Claims Act is legally protected from harassment, suspension, or being fired as a result of their reporting. If the court finds the employee did suffer discrimination, they may be awarded two times their back pay (with interest), immediate reinstatement of their original job, and additional compensation for costs incurred and any damages suffered as a result.

When the Qui Tam Provision May Apply

Qui tam is an abbreviation for a Latin phrase that very loosely translates to someone who brings a case on behalf of themselves and their “king”. Basically, it means you can sue someone on behalf of the government, and be paid a percentage of any of the funds recovered as a result of the lawsuit, even if you were engaged in, or a part of, any illegal activities covered by the FCA.

It is worth noting here that any awards received as qui tam payments are considered ordinary income, and taxed as such by IRS. While previous qui tam relators have attempted to have these payments classified as capital gains, the Ninth Circuit Court of Appeals upheld the IRS’ position on income classification.

Think You Have a False Claim Act for Healthcare Case?

Contact the experienced attorneys at Bothwell Law Group by calling 770.643.1606, and find out if the False Claim Act for healthcare applies to your situation.

Does Unnecessary Medical Billing Fall under the False Claims Act?

Unnecessary medical billing

When reading the False Claim Act, it may not seem perfectly clear whether unnecessary medical billing is covered by the law. The False Claims Act is a detailed law, covering multiple industries and various types of fraud. If you suspect a healthcare provider of committing fraud, there are a few things you should know before taking action under the False Claims Act.

What Is Unnecessary Medical Billing?

Unnecessary medical billing can take many forms. In some cases, a physician will bill for a service never provided or upcode a service as a more expensive test or procedure in order to obtain further compensation. In other cases, the healthcare provider will intentionally misdiagnose a patient, knowing this diagnosis will enable them to bill for costlier tests and procedures the patient never needed. Another example of unnecessary medical billing occurs when a patient is provided a service or supply they never needed because the healthcare provider is hoping to receive additional funds.

Not All Unnecessary Medical Billing Falls under the False Claims Act

All unnecessary medical billing is wrong, but not all unnecessary medical billing falls under the False Claims Act. This law was specifically created to allow for prosecution of entities which are misusing government funds. This means, any unnecessary medical billing being paid by Medicare or Medicaid will fall under the law. The False Claims Act allow for citizens to act on behalf on the behalf of U.S. government by filing a complaint.

This is compared to cases where a private insurance company is being billed unnecessarily. This type of insurance fraud is not covered under the False Claims Act, but it is illegal. The private insurance company will need to seek out an attorney who can work with them to file a lawsuit on their behalf.

Reporting Medicare or Medicaid Fraud

If you are the employee at an organization which receives reimbursement for services from Medicare or Medicaid and you suspect fraud is being committed, you can become a whistleblower. If you are a recipient of services being paid for through Medicare or Medicaid, you can also report fraud. Many people choose to report fraud through a hotline provider by the Attorney General in their state. However, if you wish to receive up to 25 percent of the recovered funds as a reward for filing a complaint, you must work with an attorney to file a claim.

An experienced whistleblower attorney will be able to guide you through each step of the process. They can make sure you are protected against retaliation for filing the complaint and they can help you take every possible step to increase your chance of receiving a portion of the recovered funds.

At Bothwell Law Group, we are experienced working with whistleblower lawsuits. To learn more about unnecessary medical billing and the False Claims Act, call 770.643.1606.

What Is Medicare Billing Fraud?

Medicare Billing Fraud

Medicare Billing FraudEven if you are highly familiar with Medicare, it may not be easy to spot Medicare billing fraud. Medicare is an insurance program provided by the federal government to individuals who are 65 years old or older. Additionally, young people with qualifying disabilities and individuals with end-stage renal disease may qualify for Medicare coverage.

What Is Medicare Billing Fraud?

Medicare fraud occurs when a healthcare provider gives false information to Medicare. As a result, the provider receives additional compensation beyond what is appropriate. In some cases, this may be as obvious as billing for a service never received. In other cases, such as unbundling a service in order to bill at a higher rate, the Medicare fraud is inconspicuous.

If you are the employee of a healthcare facility who receives Medicare compensation, it is important to always keep an eye out for any behavior that qualifies as Medicare fraud. If you are a recipient of services paid for by Medicare insurance, you can also play a role in reporting fraud. The False Claims Act indicates fraudulent activity can come in many forms, but with enough knowledge you can quickly spot a healthcare scam and become a whistleblower.

Examples of Medicare Billing Fraud

Medicare billing fraud can take on many different forms. In each circumstance, fraud always has one thing in common—medical information is being misrepresented and government funds are being misused as a result. Here are a few examples that qualify as Medicare billing fraud:

  • A physician bills for a service, but the patient never received that service.
  • A medical supply distributor submits for reimbursement for supplies never received by the person covered under Medicare.
  • A false diagnosis is documented, allowing the healthcare provider to receive compensation for more expensive services or supplies.
  • A group of services that are normally billed as one, such as a complete blood count, is unbundled into individual services, resulting in higher compensation.
  • A medication is prescribed after the physician receives kickbacks from the company producing the medication.
  • A test or procedure is upcoded, or billed as a more expensive service.

The Cost of Medicare Billing Fraud

When Medicare billing fraud occurs, government funds set aside for providing healthcare services for individuals over 65, young people with certain disabilities, or end-of-life conditions are improperly used. Loss of government funds is not the only consequence created by fraudulent behavior; it causes healthcare costs to rise for everyone in the United States.

If you suspect a healthcare provider of Medicare billing fraud, you can become a whistleblower. Your cooperation will not only play a role of reducing the occurrences of fraud within the healthcare system, you may also be rewarded. Under the False Claims Act, whistleblowers may receive as much as 25 percent of the recovered government funds resulting from the lawsuit. Without an attorney, you do not qualify for the rewards outlined by the False Claims Act and you cannot be protected from retaliation.

To learn more about becoming a Medicare fraud whistleblower, call 770.643.1606 to speak an experienced attorney at Bothwell Law Group.

Hospice Pays $3 Million in Fraud Claims Settlement

fraud claims settlement

fraud claims settlementIn a recent fraud claims settlement by Bothwell Law Group, Georgia area hospice center Guardian Hospice has reached a $3 million settlement. Together with their affiliated organizations, Guardian Home Care Holdings and AccentCare, Guardian Hospice was accused by a whistleblower of submitting false claims to Medicare and Medicaid.

The false claims submitted were for hospice patients in their care who were not terminally ill and they obtained government funds by providing this false information. Bothwell Law Group used the settling of this lawsuit to pursue justice for two former Guardian employees whose sealed case was filed in 2012. Although Guardian did not admit to being liable for the fraud, they still agreed to a $3 million settlement.

What can we learn from this fraud claims settlement?

Since the whistleblowers in this case filed their claim under the False Claims Act, Bothwell law was able to obtain a $510,000 reward for their actions. In addition to this, two of the whistleblowers believed Guardian wrongfully terminated them. As a result, Bothwell was able to negotiate an additional $50,000 for Rose Betts and $40,000 for Jennifer Williams to resolve the retaliation they claimed to have faced at the hands of their former employers.

In a statement to the media, Bothwell shared that their clients had grown accustom to watching their employer offer hospice care to non-terminal patients. In order to receive reimbursement for their care, the hospice center submitted false claims to Medicare and Medicaid, communicating that these patients were in the last six months of their lives.

In a statement concerning the case, Derrick Jackson, special agent who was placed in charge of the U.S. Department of Health and Human Services Office of the Inspector General, explained why this is such a gross misuse of funds.

“Hospice care is only medically appropriate—and reimbursed by Medicare—for terminally ill patients who are in the last months of their lives,” Jackson stated.

Mike Bothwell, and the entire team at Bothwell Law were honored to work closely with the honest and brave whistleblowers who brought the fraud to the attention of the United States government. Throughout the case if was very clear the U.S. government was not the only victim of the fraudulent actions.

Patients who do not meet criteria for hospice care, but are admitted anyway, miss out on the treatment a traditional hospital would provide, potentially missing a chance for their illness to be cured. Without the actions of the whistleblowers, who were wise when they selected a law firm that was experienced in whistleblower law and fraud claims settlement, this fraud might have continued to be committed in the future.

If you have reason to believe your employer may be committing Medicare or Medicaid fraud, call 770.643.1606 to learn more about filing a fraud claims settlement with our legal team Bothwell Law Group.