Healthcare Fraud
Our nations’ federal and state governments annually spend hundreds of billions of taxpayer dollars on government funded healthcare and prescriptions drug programs. These vast sums provide needed healthcare access to the most vulnerable in our communities. The funding for these programs comes straight from the pockets of hardworking citizens. When a doctor or medical facility acts fraudulently with these resources, it ultimately hurts the public more than the government, as they’re the ones who will ultimately pay the price through their own tax dollars. Unfortunately, healthcare fraud is the most commonplace fraud, but that doesn’t mean we have to stand idly while it occurs.
In fact, under federal and state False Claims Act (FCA) statutes, ordinary citizens can file whistleblower/qui tam lawsuits in federal and state courts. These lawsuits are intended to give the government information and evidence of the fraud. If the government successfully pursues and recovers monies from the defendants named in the lawsuits, the whistleblower may be entitled between 15-30% of all the monies the government recovers.
Who Can Blow the Whistle on Hospitals, Doctors Offices, and Other Medical Facilities?
In many cases, medical facilities that are committing fraud will conceal their wrongdoing from the public and behind closed doors. Anyone within or outside the organization who has knowledge of overbilling, the payment of illegal kickbacks, or any other fraudulent activity can file a lawsuit on behalf of the government, such as:
Whistleblowers tend to be apprehensive about coming forward and volunteering information regarding fraud in the workplace. This concern is based upon the fear of facing retaliation from their employer. However, the federal and state laws contain provisions that provide qualified whistleblowers with legal remedies if they experience retaliation from their employer. Our experienced attorneys will guide you throughout this process and ensure your legal options are protected.
Qui Tam Lawsuits: Types of Fraud
Fraud occurs when a doctor’s office, hospital, or other medical facility attempts to deceive the federal government for its own financial gain. Whistleblower lawsuits have arisen from all types of fraud, including:
Phantom Billing
Phantom billing, or the billing for uncharged services, occurs when a medical facility charges the government for services they never performed.
Billing for Unnecessary Services
Doctors and other medical staff may perform medically unnecessary services on their patients to bolster their organization’s finances. Once the procedure is completed, the medical professional will send their bill to Medicare/Medicaid, then fraudulently collect money that isn’t rightfully theirs.
Kickbacks
Any person or entity that makes or accepts payments for referring, recommending, or arranging for the purchase of items that are paid for by government funded healthcare programs may be in violation of the law.
Up-Coding
When a healthcare organization fraudulently alters diagnosis or treatment codes to become eligible for increased reimbursements from the government, it’s considered to be “Up-Coding.” This behavior is difficult to detect unless you’re close to the source, which makes the involvement of a whistleblower much more important.
Unbundling
Unbundling occurs when a healthcare provider bills separately for related services that are properly billed under a single procedure or code. By separating expenses, the healthcare provider aims to improperly seek greater reimbursements.
Double Billing
Laws and regulations specifically prohibits healthcare providers and organizations from charging twice for a service that was only performed once.
Waiving Co-Pays
The waiver of co-pays for government health plan patients is frequently used to improperly incentivize beneficiaries in obtaining goods and services. Government healthcare plans require co-pays as it’s a useful mechanism to ensure beneficiaries have a financial interest in the care they receive. Without that financial interest, there really is no obstacle to over-utilization of healthcare goods and services.
Substitution of Generic Drugs
Prescription drugs differ in price depending on their manufacturer. If a healthcare organization knowingly gives a patient a generic drug and charges the Government health plan for the name-brand alternative, then fraud has occurred.
Noncompliance with FDA Regulations
The FDA has a long list of regulations that the manufacturers of medical equipment and prescription drugs must adhere to for their products to be used in a healthcare setting. These regulations coincide with the current Good Manufacturing Practice (cGMP) and are used to ensure that all the equipment that medical professionals use is safe for its intended purpose. Any violation of these rules and regulations may result in penalties.
Knowingly Providing Defective Medical Products or Services
Prescription drug companies, medical device manufacturers, and other healthcare organizations can be held liable if they knowingly provide services or products that are defective.
Does Exposing Medicare Fraud Violate HIPAA Guidelines?
The Health Insurance Portability and Accountability Act of 1996, also known as HIPAA, is a law that dictated national standards that were designed to prevent the unauthorized release of Protected Health Information (PHI). There are significant penalties for persons or entities that knowingly expose or fail to disclose the unauthorized release of PHI. However, HIPAA’s privacy rule contains a Permitted Use/Disclosure clause that allows individuals or entities to use PHI, not otherwise authorized, so long as it’s used in good faith and involves a question of professional misconduct, such as fraud.
Together, We Can Stop Medicare Fraud at Hospitals, Pharmacies, & Healthcare Organizations
Any entity or individual billing federal healthcare programs has the potential and opportunity to commit fraud. Thus, the reason why whistleblowers are so important for detecting and recovering healthcare fraud. In fact, the Department of Justice recently reported that of the $5.6 billion in Federal FCA successfully resolved cases in 2021, $5.0 billion involved healthcare.
That’s why our nation needs whistleblowers, and we’re here to ensure that the process moves as easily as possible for anyone who has evidence of fraudulent activity. Our team of highly experienced and successful whistleblower attorneys, former FBI agents, and dedicated support staff are ready to help you take the first step.
As a qualified whistleblower, you may be entitled to between 15% - 30% of the amount recovered. The FCA statute requires that a whistleblower have an attorney and an experienced whistleblower attorney, one solely dedicated to this unique practice, will be able to maximize your reward, Thus, if you have knowledge and evidence of government funded healthcare fraud, please contact us today for your free and confidential consultation with our whistleblower qui tam team.