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What Types of Healthcare Fraud Are Most Commonly Reported under Whistleblower Legislation?

Types of Healthcare Fraud

Types of Healthcare FraudThere are many types of healthcare fraud, and the United States government relies heavily on whistleblowers who report fraudulent activity. Anytime a healthcare provider uses misrepresentation on an insurance claim, this is fraud. The False Claims Act makes it possible for healthcare employees to report evidence of fraud in their workplace. Healthcare fraud costs millions of dollars every year.

If you are an employee at a healthcare organization, you can keep an eye out for these most commonly reported health care fraud activities and aid in recovery of government funds:

Health Care Fraud Scheme #1: Billing for Service or Product Never Provided

In some cases, physicians or billing departments will attempt to collect additional money by billing Medicare or Medicaid for services or products they never provided to a patient.

Health Care Fraud Scheme #2: Separate Billing of Services Normally Bundled as One

Many diagnostic tests and procedures are commonly bundled together as one on insurance claims. In some cases, healthcare providers will bill for the bundled procedure and then unbundle the service and bill for each test individually in order to obtain double payment.

Health Care Fraud Scheme #3: Double Billing

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

Health Care Fraud Scheme #4: Incorrectly Diagnosing a Patient

There are some healthcare services that are only provided by Medicare or Medicaid when the patient has a specific diagnosis. In order to obtain payment for a higher paying procedure, some health care professional may falsely diagnose their patient.

Health Care Fraud Scheme #5: Billing an Uncovered Service as Covered

This type of fraud often happens when a physician is doing a favor for a patient. They want to provide a non-covered service for the patient. Therefore, they bill it as a covered service. Even though motivated by their desire to help out their patients, it is still healthcare fraud.

Health Care Fraud Scheme #6: Accepting Kickbacks from Vendors

The pharmaceutical and medical supply industry is a highly competitive business. Because of this, some vendors may engage in unethical activity to bias physicians to use their product. Anytime a physician accepts a kickback or bribe from a vendor, they commit healthcare fraud.

Health Care Fraud Scheme #7: Use of Unnecessary Services

In some cases, physicians will provide patients with unnecessary services or products normally paid by Medicare or Medicaid. This allows them to receive payment for services they never should have performed.

If you work at a healthcare organization and you suspect your employer may be committing one of the fraudulent activities listed above, you can file a complaint under whistleblower legislation. The laws in place enable to whistleblowers to file a lawsuit on behalf of United States government. Whistleblowers can receive protection from retaliation at the hands of their employer. Also, they may receive a portion of the recovered funds.

Have questions about the different types of healthcare fraud that exist? Click here to get the answers you need from our team at Bothwell Law Group.

Over $3 Billion in Fines and Damages

Fines and Damages

Fines and DamagesWhat happens when a company uses kickbacks to boost sales of drugs? They are liable to pay fines and damages in the millions or even in the billions of dollars!

False Claims Act Violation – over $3 Billion in Fines and Damages

According to documents filed in federal court in New York, another drug company, Novartis, used kickbacks to boost the sales of two drugs. This caused the federal health care programs to overpay for medicine. The U.S Department of Justice claims Novartis should pay up to $3.35 billion in damages, including $1.52 billion in damages and $1.83 billion in fines. The Justice Department tripled the amount of money Medicare and Medicaid paid for the drugs as a result of kickbacks between 2004 and 2013.

False Claims Act Violation

The two drugs are the Myfortic treatment for kidney transplants and Exjade which is used for patients with blood transfusions. Novartis reportedly used rebates and different plans to induce specialty pharmacies to boost prescriptions. This is a violation of the False Claims Act.

According to court documents, a whistleblower lawsuit was filed by a former Novartis employee, alleging Novartis paid for lavish trips. It also claimed that speaker dinners given for doctors were purportedly kickbacks used to induce them to prescribe Novartis drugs. The feds joined this lawsuit.

Another Whistleblower lawsuit against Novartis

In 2011, a former Novartis sales manager, David Kester, filed a whistleblower lawsuit. About a dozen states and the Justice Department joined the litigation. A trial date for the lawsuit brought by the feds is set to start in November.

Why has this case been so closely watched?

A key issue is the extent to which a so-called Corporate Integrity Agreement (CIA) that Novartis signed in 2010 might factor into the proceedings. Such agreements usually run for five years and require companies to establish internal compliance programs and report violations.

When the lawsuit against Novartis was announced two years ago by Preet Bharara, a U.S. Attorney in New York, Bharara called Novartis a “repeat offender”. The law suit did note that the violations alleged in the litigation took place before and after the CIA was signed.

What happens if Novartis loses the case?

The drug maker, Novartis, could potentially face being excluded from having contracts with federal health care programs – resulting in a large loss of revenue.

However, if they are excluded, it could unnecessarily harm many patients, as Novartis provides numerous needed medications.

We will keep you posted about the events and outcome of this large False Claims Act case.