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

The Process for Lawsuits That Stem from the False Claims Act and Medicare

False Claims Act and Medicare

False Claims Act and MedicareLawsuits stemming from the False Claims Act and Medicare fraud are unique. They follow an entirely different process than normal civil litigation, and it’s important to understand the key differences before filing suit. Because the process is so distinct, you need to have a firm understanding of the ins and outs; otherwise, your suit could be over before it’s even begun.

Here’s a simplified breakdown of how the process works, and how you should proceed as you determine whether or not to file suit:

Gather the Evidence about Medicare Fraud, but Keep Quiet

This might seem like a no-brainer, but hearsay isn’t enough of a reason to go to court. Before you do anything rash, determine whether you have a way to prove your allegations. Needless to say, the stronger your evidence, the more likely you are to receive a favorable judgment or settlement. Anything in writing or in the form of digital files is your best bet: emails, receipts, paper reports, sales records, and so forth.

It’s also critical that you don’t tell anyone about your suspicions, or your possible lawsuit. We’ll explain more about why in a later section, but it’s best to stay mum on your findings until you….

Hire a Lawyer Who’s Got Medicare Fraud Law Experience

You’ll want to interview a few lawyers before settling on the right one. However, you should be looking for someone with a few key characteristics:

  • Experience winning cases comparable to yours
  • They’re straight-forward; they won’t promise you’ll win, but they will tell you the odds and how you can improve them
  • They’ll listen to your goals; if you don’t want to drag out a trial for years, they’ll tell you your options and be willing to adjust their strategy accordingly

Once you have the lawyer, next comes the hard part.

Deciding Whether or Not to File a Qui Tam Suit

There are a lot of things to consider when determining whether or not to press forward with a qui tam lawsuit. Various job, personal and social ramifications are unprotected by the law, and you need to decide if filing this lawsuit is going to be worth it. If you hired an experienced lawyer in the previous step, he or she should be willing to lay these out for you in detail.

If you decide to press forward, this is when you…

File the Fraud Complaint Under Seal

“Under Seal” is a fancy way of saying “in secret.” You and your legal team will file with the Court, who, in turn, alerts the government. The government will then review your materials and launch an investigation. This part is critical; your employer will not be aware they are being investigated. This is precisely the reason we told you to keep your suspicions to yourself early on. If anyone violates the under seal order, it could cause the lawsuit to be thrown out.

The Government Makes a Decision on Whether or Not to Intervene

Based on the size of the prize and the strength of the evidence, the government will determine whether to intervene, or join your case. In other words, they decide if they want to take it over on their own, or let you carry it forward on their behalf.

If they join you, your odds of winning a favorable ruling or settlement go up significantly. However, your portion of the recovery will top out around 20%.

If they don’t join you, you can still carry the suit forward on your own. Depending on your case, you may still have a very strong chance of a favorable outcome. What’s more? Your portion of the recovery can be as much as 30%; a result of the inherent risk you’re taking by going it alone.

The Outcome of False Claims Act and Medicare Lawsuits

Either your case will go to court, or the company you sued will opt for an out-of-court settlement. Either way, you’ve made it to the end of the road, and a portion of the funds is now yours!

Still have questions about the False Claims Act and Medicare fraud lawsuits? 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.

Bothwell Law Works on Case Of Medicare Fraud in State of Tennessee

Tennessee Medicare Fraud Case

Tennessee Medicare Fraud CaseNationally recognized whistleblower attorney, Mike Bothwell aided in building yet another case of Medicare and Medicaid fraud. Nashville Pharmacy Services, LLC and majority owner Kevin Hartman will pay up to $7.8 million in response to allegations the company overbilled Medicare and TennCare for pharmacy services. Aided by Bothwell’s initial work on the case, the state of Tennessee reached the settlement and closed its case against the company for alleged false claims submitted from February 2011 to May 2012.

Marsha McCullough acted as the whistleblower to set the case in motion. McCullough worked for Nashville Pharmacy Services as an entry technician from May 2011 to June 2012. During that period she alleges that the company billed Medicare and TennCare for certain medications that were dispensed after the dates of death of at least 15 beneficiaries with Medicare and TennCare coverage.

Bothwell and co-counsel filed her claims under the qui tam, or whistleblower, provisions of the Federal State and False Claims Act. The FCA allows citizens with insider knowledge of fraud, waste and abuse to bring legal action on behalf of the government in order to put a stop to the fraud. In cases won, the government has recovered up to three times the amount defrauded, with whistleblowers receiving anywhere from 15 to 30 percent in return.

In this particular case, the United States government will receive roughly 49% of the recovered settlement while the State of Tennessee will take in around 33% of the settled amount. As a whistleblower on the case, McCullough could receive up to $1.4 million of the reached settlement.

This is just one of many cases of Medicare and Medicaid fraud that attorney Mike Bothwell has worked on. Bothwell is a prominent whistleblower attorney whose efforts to stand up for those who speak out in cases of fraud have aided the U.S. government in the ongoing battle to stop Medicare and Medicaid fraud

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

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.

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.

10 Reasons to Hire a Medical Malpractice Attorney

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.

Medicare Fraud Whistleblower: What Are the Rules?

Medicare Fraud Whistleblower

Medicare Fraud WhistleblowerIf you know of Medicare Fraud, you may have occasion to be a Medicare Fraud Whistleblower. It’s important to know what the rules are.

One such whistleblower, Jacqueline Bloink, initiated a legal action resulting in a $35 million settlement to the federal government. Bloink is a former employee of the Carondelet Health Network and provided evidence of them submitting false claims to Medicare.

As a result, Medicare Fraud Whistleblower, Jacqueline Bloink, earned nearly $6 million.

What is considered Medicare Fraud?

  • Knowingly submitting false statements or misrepresenting facts to get federal health care payment when an entitlement would not exist otherwise;
  • Knowingly paying, soliciting, and/or accepting remuneration to reward or induce referrals for services or items reimbursed by Federal health care programs;
  • Making prohibited referrals for certain designated health services.

Obviously, defrauding the Federal government is illegal. Criminal and civil remedies for committing Medicare fraud include:

  • Fines
  • Imprisonment
  • Penalties
  • Exclusion from participation in Federal health care programs
  • Loss of professional licenses

5 Laws Governing Medicare Fraud:

  • United States Criminal Code
  • Anti-Kickback Statue (AKS)
  • False Claims Act (FCA)
  • Physician Self-Referral Law (Stark Law)
  • Social Security Act

5 Conditions That Must Be Met according to

  1. You report your suspected Medicare fraud. The allegation must be specific, not general.
  2. The suspected Medicare fraud you report must be confirmed as potential fraud by the Program Safeguard Contractor, the Zone Program Integrity Contractor, or the Medicare Drug Integrity Contractor (the Medicare contractors responsible for investigating potential fraud and abuse) and formally referred as part of a case by one of the contractors to the Office of Inspector General for further investigation.
  3. You aren’t an “excluded individual.”


For example, you didn’t participate in the fraud offense being reported. Or, there isn’t another reward that you qualify for under another government program.

  1. The person or organization you’re reporting isn’t already under investigation by law enforcement.
  2. Your report leads directly to the recovery of at least $100 of Medicare money.

For more information about the Medicare Fraud Whistleblower Rules, have a confidential consultation with an experienced Whistleblower Attorney. They can help you navigate the tricky waters of a whistleblower law suit and help protect your rights. It’s important to know the rules, know your rights, know the laws surrounding Medicare and whistleblowing, and know the process inside and out.

What a Business Fraud Lawyer Can Do For You

Business Fraud Lawyer

Business Fraud LawyerBusiness fraud refers to a number of business practices that are deceitful and unlawful. Acts of fraud range from businesses using accounting practices that disguise their profits from the Internal Revenue Service (IRS) and to mislead investors to advertising non-existent features of a product to increase its sales potential. Some businesses have been found to use business and corporate funds for their own private enjoyment. Some of these cases make the news and involve prominent figures.

Business fraud has been broadly defined as when a “person or business intentionally deceives another with promises of goods, services, or financial benefits that do not exist, were never intended to be provided, or were misrepresented.”  Unfortunately, business fraud affects everyone. If you have been a victim of any of the following, a business fraud lawyer may be able to help.

  • Billed for services not received.
  • Billed for products not ordered.
  • Been overcharged for products or services.
  • Using a product that appeared safe when the manufacturer knew there were dangers to the use but kept those dangers secret.

The list could go on and on. There are certain elements you must prove in order to collect damages for the fraudulent acts of a business.

A business fraud lawyer will evaluate your situation and determine if you have a legal case

There are five things you must prove in order to win a business fraud case:

  • There was a false representation of fact.
  • The representation was made by a representative of the company or the company itself.
  • The person making the false representation knew at the time the representation was false.
  • The false statement was made for the purpose of inducing you to act or not act based on the content of the statement.
  • You suffered damages by relying on the false statement by acting or refraining from acting.

The false representations are not required to be made orally or in writing. A gesture, nod of the head or failure to provide information can all amount to an intentionally false or misleading statement.

It may seem easy to you. You simply know the business representative knew what he or she was telling you was false. The difficult thing to prove is that the person acted intentionally to deceive you and induce you to act. An experienced business fraud lawyer will know the questions to ask and information to obtain in order to prove business fraud occurred and the damages to which you are entitled to as a result.

If you believe you have been the victim of business fraud, or work for a company that engages in business fraud practices, contact a business fraud lawyer who will review the facts of your case and help you decide what to do next.

$202 Million GA Medicare Fraud Case Starts Aug 3

False Claims Act | SEC Whistleblower Claim

Another Medicare Fraud Case under the False Claims Act

The Department of Justice (DOJ) intends to prove AseraCare is liable under the False Claims Act “because it caused non-terminally ill patients to prematurely give up curative or rehabilitative care so that the company could bill Medicare for hospice payments” according to DOJ attorneys.

A court document from the DOJ attorneys stated “In short, the United States’ told U.S. District Court Judge Karon Bowdre in one court document. “To the contrary, the United States brought this case based on evidence that AseraCare marginalized doctors, systematically pressured its own clinical staff to admit and keep ineligible patients, submitted false hospice claims for patients who were not terminally ill, and was put on notice from internal and external audits and employee complaints that this was occurring.”

Trial Date Set for August 3

A federal judge in Birmingham set a trial date of August 3 for this lawsuit which began when half a dozen AseraCare employees in Georgia, Alabama and Wisconsin filed whistleblower cases.

According to Patrick Burns, co-director of the Washington nonprofit Taxpayers Against Fraud Educational Fund, “It will be, far and away, the biggest hospice (FCA) case.”

Why $202 Million?

The DOJ analyzed random samples of 2,181 AseraCare patients for whom the company billed Medicare for at least 365 consecutive days of hospice care.  Patients were with AseraCare for two periods: Jan. 1, 2007 and Dec. 31, 2008 and between Jan. 1, 2009 and Feb. 28, 2011.

The findings: The DOJ argued more than half of the 233 cases should have been deemed ineligible for hospice care.

“Having a few patients who live longer than six months is expected”, Burns said.  “That should be one in a hundred, not fifty percent,” he said.

DOJ claims Medicare suffered nearly $67.5 million in damages due to the False Claims Act violations. According to the DOJ’s motion, if the jury awards the $67.5 million, then the judge is obligated under the law to treble the actual damages and award the U.S. a total of $202,481,144.

Congress created the Medicare hospice benefit in 1982. According to court documents, Roughly 90 percent of hospice patients are now covered by Medicare and/or Medicaid.

We will keep you posted on the events of this case. The law firm for the whistleblowers in this case is Frohsin & Barger LLC.

If you know of any Medicare or Medicaid fraud, contact a Whistleblower Attorney today!



Historical Amount of Medicare Fraud Arrests

Despite the historical number of Medicare fraud arrests, more are set to come. 

According to Modern Healthcare reporter Lisa Schencker, “Federal officials announced Thursday the largest coordinated, criminal Medicare fraud takedown—and the first large-scale effort to focus on Medicare Part D fraud—in the history of the U.S. Justice Department.

Over the last three days, the Medicare Fraud Strike Force has unveiled charges against 243 individuals across the country accused of falsely billing $712 million to Medicare in a number of separate schemes, said U.S. Attorney General Loretta Lynch. Those charged include 46 doctors, nurses and other licensed medical professionals.”

Of those arrested, more than 44 have been charged with fraud related to Medicare’s drug benefit program – Medicare Part D.

HHS Inspector General Daniel Levinson said costs in Medicare Part D reached $121 billion last year. “Our focus on Medicare Part D continues because more than 41 million Americans depend on that program, and its integrity must be protected,” Levinson said.

Law firms, like Health Law Partners, are starting to see a lot of fraud enforcement in the pharmacy area.

Medicare Part D More Difficult to Prosecute

Since Medicare Part D payments are capitated, instead of being fee-for-service, prosecuting in this area can be more difficult to prosecute than other areas of Medicade, according to Patrick Burns, co-director of the Taxpayers Against Fraud Education Fund.

Tony Maida, a former deputy chief of the administrative and civil remedies branch of HHS’ Office of Inspector General, also noted in a statement that the announcement Thursday “was packaged together by the government to create a high level of media and public exposure, as well as for a deterrent effect.”

Types of Charges Against the 243 Individuals

In this latest federal effort to crack down on fraud, the 243 individuals accused were charged with a variety of crimes including “conspiracy to commit healthcare fraud, violating the anti-kickback statute, money laundering and aggravated identity theft in areas including home healthcare, psychotherapy, physical and occupational therapy, durable medical equipment and pharmacy fraud.”

Who’s Investigating These Cases?

Medicare Strike Force teams from the Fraud Section of the Justice Department’s Criminal Division as well as U.S. attorney’s offices around the country are prosecuting and investigating these cases.

If you are aware of Medicare fraud, contact a Medicare Fraud Attorney as soon as possible.


Children’s Hospital Pays Millions in Settlement

Hospitals around the country have been accused of violating the false claims act.  Children’s Hospital in D.C. is among them.

The allegations against Children’s Hospital

Children’s Hospital, Children’s National Medical Center Inc. and it’s affiliated entities, collectively known as CNMC faced claims of violating the False Claims Act. They are accused of submitting false claims reports and other applications to the Department of Health and Human Services (HHS) and to Medicaid programs in Virginia and the District of Columbia.

Violating False Claims Act Raises Health Care Costs for Everyone

“The false reporting alleged in today’s settlement deprived the Medicare Trust Fund of millions of taxpayers’ dollars,” said Principal Deputy Assistant Attorney General Benjamin C. Mizer of the Justice Department’s Civil Division.  “Such conduct wastes critical federal health care program funds and drives up the costs of health care for all of us.”
“The integrity of federal health care programs depends on honest and accurate reporting from the hospitals and other health care providers that receive hundreds of billions of tax dollars every year,” said Acting U.S. Attorney Vincent H. Cohen Jr. of the District of Columbia.  “This settlement demonstrates our commitment to defending the integrity of the system and ensuring that taxpayer money goes to meet the most critical health care needs.  We will continue to work with whistleblowers like the former employee who came forward in this case to battle waste, fraud and abuse that fuel the skyrocketing cost of health care.”

The settlement Agreement

Children’s Hospital agreed to pay $12.9 million in a settlement agreement. According to the settlement agreement, in two distinct ways, CNMC misstated information on cost reports and applications.  The HHS and Medicaid programs used the false information to calculate reimbursement rates to CNMC. The United States contended that CNMC falsely reported its available bed count on its application to HHS’ Health Resources and Services Administration under the Children’s Hospitals Graduation Medical Education (CHGME) Payment Program. This program provides federal funds to freestanding children’s hospitals to help maintain their graduate medical education programs. Such programs train pediatric and other residents.

The United States further contended that CNMC filed cost reports which misstated their overhead costs. These false reports resulted in overpayment from Medicare as well as the Virginia and District of Columbia Medicaid programs.

Allegations against CNMC were filed by James A. Roark Sr., a former employee of CNMC, under the qui tam or whistleblower provisions of the False Claims Act.  Under the False Claims Act, a private citizen can sue on behalf of the United States and share in any recovery. The United States is entitled to intervene in a False Claims Act lawsuit, as it did in this case.

From the $12.9 million settlement, Mr. Roark will receive $1,890,649.98.

Health Care Fraud Prevention and Enforcement Action Team (HEAT) Initiative

In May 2009, the Attorney General and the Secretary of Health and Human Services announced the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative. This was done in efforts to combat health care fraud. The two departments are working together to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of their most powerful tools is the False Claims Act.

$24.3 billion has been recovered through False Claims Act cases since January 2009. More than $15.3 billion involves fraud against federal health care programs.
Please note: This particular matter was handled by the U.S. Attorney’s Office of the District of Columbia with assistance from the Civil Division’s Commercial Litigation Branch and the HHS’ Office of Inspector General.
The case is United States ex rel. Roark v. Children’s Hosp., et al., No. 1:14-cv-00616 (D.D.C.).
The claims resolved by the settlement are allegations only, and there has been no determination of liability.


$15 Million False Claims Act Settlement

False Claims Act | SEC Whistleblower Claim

Sixteen Hospitals Violate False Claims Act to the Tune of $15.69 Million

According to the US Justice Department, 16 hospitals across the country will repay the federal government nearly $15.79 million for claims submitted to Medicare for services deemed unreasonable or unnecessary. This is one of the largest violations of the False Claims Act to date.

The Involved Hospitals

Health Management Associates Inc., or HMA, owns and operates 14 of the involved hospitals. They include Central Mississippi Medical Center, Crossgate River Oaks (Mississippi), Dallas Regional Medical Center (Texas), Davis Regional Medical Center (North Carolina), East Georgia Regional Medical Center, Gilmore Regional Medical Center (Mississippi), Lake Norman Regional Medical Center (North Carolina), Lehigh Regional Medical Center (Florida), Medical Center of Southeastern Oklahoma, Natchez Community Hospital (Mississippi), Santa Rosa Medical Center (Florida), Southwest Regional Medical Center (Arkansas), and Summit Medical Center (Arkansas). Between the 14 hospitals, a payment of $15 million will reimburse the federal Medicare program. Wesley Medical Center in Mississippi will pay $210,000, and North Texas Medical Center will round out the rest with a payment of $480,000.

The Allegations

Between the years of 2015 and 2013, the 16 above hospitals allegedly billed Medicare for Intensive Outpatient Psychotherapy, or IOP services, which are programs designed to treat individuals with serious mental disorders, that they knew were not billable. According to the claim, these hospitals billed Medicare for unqualified IOP services. According to current law, hospitals may only bill Medicare for services under certain conditions. In this case, the patients’ conditions did not qualify for IOP, staff failed to track patients’ progress properly, the patients did not receive the right level of treatment, or individualized treatment plans were not the first course of action as per Medicare’s guidelines.

The Impact on Consumers

With millions of dollars lost each year due to false and fraudulent claims like these, it is no wonder that the costs of healthcare continue to spiral out of control. Millions of people in the US rely on Medicare, a program for senior citizens and the disabled, to help them cover the enormous costs of healthcare. Due to false claims like these, the costs of healthcare are on the rise and Medicare covers less than ever before. Seniors and disabled persons who are already struggling to make ends meet must purchase expensive supplementary plans and pay exorbitant prices for many lifesaving prescription medications.

Whether the 16 hospitals above knew they were committing fraud when they submitted the claims remains unknown. However, one thing is certain: hospitals and medical centers like these need stricter guidelines for claims submissions. The Medicare program’s guidelines are indeed difficult to follow at times, but doing could save consumers tens of millions of dollars every year on the cost of insurance premiums alone.