Healthcare Fraud & Whistleblower Claims
These days, healthcare fraud cases, from drug companies to Medicare, are in the news on what feels like nearly a daily basis. Judgments and settlements often run into the tens of millions of dollars, even into the hundreds of millions. The suits generally involve some form of fraud under the False Claims Act (FCA), from fraudulent billings, to trying to get Medicare and Medicaid to pay for unapproved drug applications (known as off-label prescribing), to unnecessary testing and procedures. Healthcare fraud can encompass a wide-ranging area within medicine.
The federal government does not have nearly enough people available to investigate allegations of fraud. Therefore, they rely on whistleblowers to do the necessary legwork and bring qui tam cases in which the government can then intervene, or take part.
A successful case can produce an award of 15 to 30 percent of the settlement for the whistleblower.
The Staggering Costs of Healthcare Fraud
For every $100 we spend on healthcare in the United States, as much as $10 is lost completely. It doesn’t go toward a sick grandmother who depends on Medicare. It doesn’t go toward the poverty-stricken family in need of funds to pay for a sick family member. It doesn’t even go to the less emotionally appealing aspects of our healthcare system, like document processing or claims management. That $10 is simply gone.
Where does this 10 percent go? It is lost to fraud, abuse or waste in our healthcare system. The Federal Bureau of Investigation says that tens of billions of dollars are lost to fraud every single year, while other estimates are even larger.
Facts About Healthcare Fraud
There’s good news and bad news on the healthcare fraud front. First, the bad:
- Healthcare fraud steals tens of billions of dollars annually from U.S. taxpayers. No one knows exactly how much has gone missing.
- Worldwide healthcare fraud and losses have risen 25 percent since 2008.
- Medicare, by its very structure and nature, is susceptible to improper payments, making it difficult to manage.
- Various scams committed against our government’s healthcare programs are by far the largest kind of insurance fraud that exists.
However, the good news is truly good:
- Medicare’s Health Care Fraud and Abuse Control program has recovered more than $29 billion.
- The Medicare Strike Force has a 95 percent conviction rate, with an average prison sentence of four years.
- Whistleblowers were responsible for the recovery of more than $15.2 billion in healthcare funds from January 2009 through 2014. Almost all of it involved Medicare and Medicaid.
Understanding Kickbacks in the Healthcare Industry
The healthcare industry is big business in America. It also receives a significant amount of government spending. Medicaid, for example, results in over $400 billion a year in benefits. Medicare adds another $600 billion. Total spending on healthcare in the United States amounts to about 17% of our total Gross Domestic Product (GDP) at about $2.7 trillion.
With so much at stake, it is no wonder the industry is fraught with fraud, kickbacks and schemes to get an unfair “piece of the action.”
Varieties of Healthcare Fraud
Many kinds of healthcare fraud exist. Here are some of the more common ones:
- Billing for services never provided
- Upcoding (billing for more expensive services than were provided)
- Performing tests, procedures, etc., which are medically unnecessary in order to gain reimbursement
- Falsifying medical records to “prove” that medically unnecessary treatments were needed
- Misrepresenting procedures and treatments that insurance does not pay for as being covered by insurance for the purpose of gaining payments
- Unbundling (billing each step of a procedure as if it were a separate procedure in order to gain a greater payment)
- Accepting kickbacks for referring patients, including non-monetary benefits such as vacations, cars, etc.
How to Spot Medicare Fraud – and Why It’s Such a Big Problem
Medicare and Medicaid fraud are on the rise, and this problem is becoming a costly one for everyone involved. From patients seeking medical care with Medicare to the doctors receiving Medicare payments and the taxpayers who are footing the bill, Medicare fraud is a serious problem that needs to be addressed. Without change, Medicare costs will continue to increase, as will taxes, which is a bad situation for everyone.
Recent Healthcare Fraud Whistleblower Cases
Settled healthcare fraud cases cover all areas of medical care and practice. A number of recent cases are fairly high-profile, with settlements in the hundreds of millions:
- In rehabilitation therapy: The biggest nursing home therapy provider in the U.S. will pay $125 million to settle FCA allegations. It is claimed that some of Kindred/Rehabcare’s rehabilitation services were not necessary, reasonable or skilled, or they were never performed. This 2015 qui tam case was joined by the government, and the whistleblowers will receive almost $24 million.
- In hospital systems: A settlement with Adventist Health Systems amounted to $115 million. It is alleged that Adventist engaged in improper compensation practices regarding referrals and also miscoded submitted claims for greater payment. In this 2015 case, the award given to the whistleblowers has not been decided.
- In dialysis therapy: The leading provider of dialysis services, DaVita Healthcare Partners, Inc., settled two cases for $800 million over allegations of improper billing for unnecessarily wasting drugs and for physician kickbacks. In these 2014 and 2015 cases, the awards given to the whistleblowers have not been decided.
- In medical laboratories: Millennium Health, formerly known as Millennium Laboratories, resolved allegations of unnecessary drug and genetic testing, as well as illegal compensation to physicians, with a $256 million settlement. The qui tam suits will award the whistleblowers a total of nearly $32 million.
- In pharmaceuticals: A settlement of $67 million was reached with Genentech Inc. and OSI Pharmaceuticals LLC. FCA allegations concerning misleading statements of the drug’s efficacy involve Tarceva, which is used to treat non-small cell lung cancer.
- In hospice care: $18 million will be paid by Evercare Hospice and Palliative Care. It is alleged that the company submitted false claims for patients who were not terminally ill. In this 2016 case, the award given to the whistleblower has not been decided.
While healthcare whistleblowers are often insiders with access to unique information, being an insider is not a requirement when bringing a qui tam whistleblower case. Having actionable, substantive information on which to base the claim is required.
The Staggering Costs of Healthcare Fraud
Most medical practitioners are honest, caring persons doing their part to keep us all healthy. Only a few dishonest ones want to fatten their bank accounts by committing fraud, but there are enough of them that Medicare, Medicaid, and TRICARE taken together are an enormous source for whistleblower cases brought under the False Claims Act (FCA). Our national spending on these programs amounts to around $2.7 trillion dollars, and fraud is estimated to rob us of roughly 10 percent of that amount–$272 billion.
Working with whistleblowers tirelessly to shed light on fraudulent practices
If you think you have the facts needed to bring a whistleblower case, the experienced whistleblower attorneys at the Louthian Law Firm can review your case and help you file the appropriate disclosure statement. Under some circumstances, the government will intervene, or join in your lawsuit.
Your chances of succeeding are greater if your whistleblower claim is substantive, clear, and to the point. Because of this, meeting with a qualified whistleblower attorney can increase your chances of winning. The Louthian Law Firm can help you form your claim so that the government will be more inclined to intervene in your case; government intervention can sometimes increase the chances of recovering reward money. Even if the government decides not to intervene, it could still be a good idea to pursue your case without government involvement. Our strong support system can assist you through every step of the process.
For a free, confidential evaluation of your case, call the Louthian Law Firm today at 1-803-454-1200 or, if you prefer, you can fill out our online contact form.