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Tag: Medicaid Fraud

How to Report Suspected Fraud and Be a Medicaid Fraud Whistleblower

Posted on by Mike Bothwell
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.

How Insurance Agents Identify Fraudulent Insurance Claims

Posted on by Mike Bothwell
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.

When to Report Fraud When You Are Aware of Fraud

Posted on by Mike Bothwell
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.

The Single Most Important Thing to Know about State False Claims Acts

Posted on by Mike Bothwell
State False Claims Acts

State False Claims ActsState False Claims Acts vary from state to state. It’s critical to have an attorney who knows how they work to help you get the proper rewards. Without this attorney, you may feel very overwhelmed and maybe even a little lost.

Most things in life have lessons to learn and important things to know to do them in the best possible way. Babies are like that. When you bring that tiny little bundle home for the first time, it’s easy to be panic stricken over all the important things you don’t know.

State False Claims Acts are a lot like the first day with your new baby. There are a few critical things to remember. Your state’s False Claims Acts attorney will handle the rest.

Different states’ False Claims Acts are going to be different. You need to understand the most important factors stay the same. Having an attorney who knows those important factors will help you build a strong case against the fraudulent crime committed against your state government.

What Are State False Claims Acts?

The most important thing to know about state False Claims Act cases is every state has different types of False Claims Act cases they handle. Not every state handles every kind of False Claims Act fraud.

State False Claims Acts laws were created to bring suit on behalf of state governments when fraud takes place.  In response, the government allows the whistleblower part of the money recovered in court, called the reward.

At first, whistleblower or False Claims Act claims could only be filed on behalf of the federal government. Unfortunately, fraud is also committed against state agencies as well. Now people who notify their state government of fraud, known as relators, are eligible for rewards and protections as well.

Why Do I Need a State False Claims Acts Attorney?

False Claims Act cases are complicated. They must follow an exact strategy, or the government will not advocate for the case. Your chance of a successful lawsuit is increased mightily when the government steps in. Stepping in or intervening means the state decides a crime is happening. An experienced attorney knows how to structure the complaint to persuade the government to take the lead.

When state funds are stolen through fraud, your attorney needs to know how the specifics of your state laws function. Not every state has False Claims Act laws. In the states that do have them, the details can vary a lot. One of the biggest differences between states is many of them only allow False Claims Act suits for particular types of fraud.

Why Are the States Involved in False Claims Acts?

Fraudulent claims against Medicaid are some of the most common types of False Claims Acts against states. Almost every state has provision for these kinds of suits. State funding for Medicaid comes from the federal government. Because of this transfer of funding, states need to take on the responsibility to investigate fraud.

In 2006, the Deficit Reduction Act was enacted. This act contained incentives for states to create anti-fraud legislation fashioned after the federal False Claims Act. Although many states created legislation, it is usually not modeled on the federal laws.

State administrators are the primary party responsible for preventing fraud against Medicaid. But, unless their state laws changed to follow the federal laws, they are no longer eligible for any financial incentives. It isn’t a new tradition for the state to oversee fraud. The federal government should be in an overseer position and has been for decades. The federal government encourages states to work as hard as possible to search out fraud. They offer financial incentives to this end.

Unfortunately, the instances of fraud are not always readily apparent due to the sheer numbers of Medicaid cases requiring monitoring. Because of this, frauds against state Medicaid take place unfettered. By bringing the information to a state False Claims Act attorney, you can prepare a case for your state Attorney General. If the state intervenes on your behalf, they will conduct the anonymous investigation and the court action. You will receive a portion of any money recovered.

At Bothwell Law Group, we have lawyers trained and experienced in state False Claims Act cases. We will sit down with you and discuss the potential of your case. Our attorneys will direct you toward the type of evidence needed to file a case. They will provide support every step of the way. You’ll find your fears will fade as our attorneys come alongside and handle the details for you.

The law says your employer cannot retaliate against you. Our attorneys will help you protect your rights. Contact our legal team at Bothwell Law Group online today to learn more about State False Claims Acts.

How Do I Prepare for a Meeting With False Claims Act Attorneys?

Posted on by Mike Bothwell
False Claims Act Attorneys

False Claims Act AttorneysPreparing for a meeting with False Claims Act attorneys is a big item on your to-do list if you think you may have a whistleblowing case. It’s important that you carefully prepare before you walk into the office. Read on to learn what you can expect from the meeting and how you should plan for it.

What Do False Claims Act Attorneys Do?

Everyone knows there are many different types of lawyers. There are real estate attorneys and trial lawyers, tax attorneys, and criminal attorneys. Then there are False Claims Act lawyers. Knowing what this segment of the law is about will help you understand how to prepare for your meeting.

The truth is we live in a world where people are willing to cheat to make money. The government doesn’t like it when people try to trick them. In fact, the government will give you a reward if you bring them information about a fraud being committed against them by your company. They will pay a percentage of the recovery in a False Claims Act suit; also known as whistleblowing.

There are several different types of false claims suits:

There are also different ways of committing the fraud, from charging for things never provided to a patient in a clinic but billing Medicare or Medicaid, to using inferior materials on a government contract. There are many different ways people in various industries commit the crimes.

False Claims Act procedures include a lot of variables. It’s important you have an experienced attorney who focuses solely on this type of law.  The only way the government will intervene and take on the case you present is if the information crosses the threshold of truth and evidence. When the potential for gain is possibly millions of dollars, you need an attorney who has been in these particular trenches and knows how to take on the situation without looking back.

What Do I Bring with Me to Meet My False Claims Act Lawyer?

The reward in whistleblower cases ranges from 15% to 30% of the recovery, so the potential for millions is real. It won’t come easy. But with proper preparation, you help your attorney do everything within the law to present the case to the federal government.

Here are some things you can do to help make the case:

  • Keep some notes. Don’t keep them at work. Detail where documents are stored. Note where the computer files are saved. You can’t take the proof with you, but you can explain exactly where it is. The government will investigate anonymously, and your notes give them a road map.
  • Now is the time to name names. You need to list every person involved or have knowledge of the fraud. Are they friendly to the crime or justice? Do they still work there or have they been fired. The details are the breadcrumbs.
  • Talk about the big guys and what they do. Detail how the structure of the corporation under accusation works.
  • This detailed journal is where you list all the rules and laws you think were broken. Don’t be afraid to write it out. If you know things that might hurt the case or if you have a history of your own that is questionable, you need to tell that as well. If the case gets blindsided because you withheld something embarrassing, there are no second chances. Each instance of whistleblowing is limited to the first person who brings it to the government, known as the original source.

False Claims Act Attorneys Will Work to Protect You

There can be a real fear of retaliation when you consider bringing a False Claims Act to court. The law provides protection against these things. It is illegal for you to lose your job or put up with harassment. You can’t lose wages or recognition and promotions as a result of being a whistleblower.

Having an attorney who is familiar with the fear and retaliation common in these cases is valuable. Knowing your rights and having the legal backup to stand up for them is powerful. It is not uncommon, though, for it to be quite frightening at the same time. A False Claims Act attorney is an advocate who walks alongside you during this time.

If you think you may have knowledge of a False Claims Act fraud, you need to speak with an attorney. Contact the skilled False Claims Act attorneys at Bothwell Law Group by calling 770.643.1606 today.

10 Reasons to Hire a Medical Malpractice Attorney

Posted on by Mike Bothwell
Medical Malpractice Attorney

Medical Malpractice AttorneyIf you need to bring a medical claim against a doctor or hospital, you will need help. A medical malpractice attorney can make the difference in winning and losing your case.

Here are the top 10 reason you should hire a medical malpractice attorney:

Reason 1 – Medical negligence is the third leading cause of death in the United States, according to the Journal of American Medical Association (JAMA).

Reason 2 – Over $3 billion was spent in medical malpractice handouts in 2012 alone.

Reason 3 – Proving a physician violated the accepted standard of care is nearly impossible to do alone. In a Medical Malpractice case, it must be proved that a doctor did not uphold the accepted standard of care. If a doctor fails to uphold these standards constitutes negligence.

Reason4 – The defendants attorney will likely try to claim your injuries were not caused by the care your doctor did or did not give you. They may try to claim your injuries were from outside causes. Trying to defend yourself on this point often proves to be difficult. An experienced medical malpractice attorney is skilled at handling what the defense throws at you.

Reason 5 – A medical malpractice attorney can interview the patient, family members and friends to help determine if your case is actionable.

Reason 6 – As there are statutes of limitation, a medical malpractice attorney will be able to help make sure your lawsuit is filed in time. He or she will also make sure the procedural requirements are met.

Reason 7 – You usually won’t have to pay a medical malpractice attorney in advance. The typical fee structure is for a medical malpractice attorney to be paid based on a percentage of what you may collect on a settlement or a judgment.

Reason 8 – An attorney can help you recover as damages: medical bills, pain and suffering, lost earnings and lost earning capacity.

Reason 9 – Medical malpractice attorneys can help you determine if any of the following apply to your case: amputating the wrong body part, failing to diagnose a medical condition during an exam, mistakes monitoring the amount of anesthesia a patient needs, mistakes monitoring the heartbeat of an unborn child during labor, sub-standard trauma care immediately after an severe accident, failing to account for all sponges or instruments following surgery and other such neglectful acts.

Reason 10 – Special requirements exist in a medical malpractice case that do not exist is other types of law suits, such as expert testimony and medical malpractice review panels. A specialized attorney can help acquire the right experts to testify in your case.

Attempting to fight a medical malpractice case alone is often futile. Without the help of an experienced medical malpractice attorney, your case could quickly go awry and you could be left without any compensation for your pain and suffering, medical bills or other damages.

Endangering Babies For Profit

Posted on by Mike Bothwell

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

$100 Million Lawsuit Filed

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

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

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

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

Babies Permanently Damaged

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

Watch the TV interview here. 

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

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

Average Joe Jailed for Medicaid Fraud

Posted on by Mike Bothwell

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

The Average Joe vs. Corporate Fraud

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

The State’s “Amicable Settlement”

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

How Florida Legislature Views Healthcare Fraud?

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

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

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

Tennessee Hospital Medicaid Fraud

Posted on by Mike Bothwell

A recent judgement against Jackson-Madison County General Hospital in Jackson, Tennessee means that the hospital will pay $1,328,465 to make up for improperly billing Medicaid and Medicare for the placement of unnecessary cardiac devices. The whistleblower in the case, Dr. Wood D. Deming, received a share of the settlement.

The Hospital’s False Claims

From January 2004 to December 2011, Jackson-Madison County General Hospital performed dozens of unnecessary cardiac procedures on patients for the sole purpose of collecting payments from Medicaid and Medicare. Federal law only allows hospitals reimbursement for medically necessary procedures. According to Edward L. Stanton III, the United States Attorney for the Western District of Tennessee, “Billing Medicare for cardiac procedures that are not necessary or inappropriate contributes to the soaring costs of health care and harms patients.”

Blowing the Whistle

Dr. Wood D. Deming raised the allegations under the qui tam (whistleblower) provisions of the False claims Act, which allows private citizens with knowledge of fraud to act on behalf of the government and share in the recovery. As such, Dr. Deming is entitled to his share of the settlement amount, which topped out at well over one million dollars. However, at this time, the claims are only allegations and liability has not yet been determined.

Improper Placement of Stents and Cardiac Procedures

The hospital’s allegations include improperly and unnecessarily placing stents, performing angioplasties and catheterizations, and using expensive ultrasound imaging when no medical need existed. This not only helped the hospital rack up costs that Medicaid and Medicare would later reimbursed, but it also put dozens of patients in danger. Unnecessary medical procedures carry risks of infection and bleeding, so the hospital exposed these patients to a host of unnecessary risks all in the name of corporate greed, according to Dr. Deming’s claim.

Understanding Cardiac Stents

A cardiac stent is a mesh tube surgically placed inside of the coronary arteries to keep them open. Often, in coronary artery disease, a coating of plaque lines the arterial walls, which presents a great risk for heart attacks and other complications. Not all patients with coronary artery disease require stents, however, but the Jackson-Madison County General Hospital placed them in patients when no medical need existed. Often, these procedures were followed or preceded by angioplasty (balloons placed inside the arteries), catheterization, and various types of imaging. This is a very invasive procedure, and one that many patients at the hospital just did not need, according to the whistleblower.

Patients already experience a great deal of anxiety and distress when dealing with heart problems like coronary artery disease. They should not have to worry about the competency of their doctors and health professionals. Thanks to whistleblowers like Dr. Deming, cardic patients at Jackson-Madison County General Hospital can breathe a sigh of relief.

*Bothwell Law Group did not represent any parties in this case.

If you have a whistleblower case, contact us right away for a free consultation.