Healthcare providers are a vital part of New York City’s social infrastructure, taking care of sick and injured New Yorkers and allowing people to feel and function at their best. Healthcare workers can be heroes, as these past few years have clearly shown, and so unethical actions in the healthcare industry are particularly unfortunate or disheartening to those who uncover fraud or wrongful actions.
The insurance and billing process to receive medical care in New York can be confusing and unfortunately easy for unscrupulous providers to take advantage of. If you are a healthcare worker or administrator, you may come across certain red flags that make you wonder if everything is happening above board. If you have knowledge of wrongdoing, you may wonder to whom you can speak about it. The knowledgeable whistleblower attorneys at Tycko & Zavareei LLP are available to answer any questions you might have during a free and confidential legal consultation.
Healthcare Fraud and Insurance Billing
Medicare, Medicaid, and other state or federally-run insurance funds are social safety nets for vulnerable New Yorkers. They are in place to help ensure we live in a more fair society and to make access to healthcare more equitable. Especially in a large city like New York, ensuring all New Yorkers can get medical care when they need it is a necessary and honorable goal. Keeping everyone in the city healthy makes it a safer place for all New Yorkers to live.
Unfortunately, healthcare fraud against government-provided funds is not uncommon. Attempting to scam the system and draw more than a fair share of public funds hurts not only those New Yorkers who need access to healthcare but also the taxpayers whose paychecks contribute to funding social services. Ultimately, healthcare fraud is not a victimless crime. Anyone can be harmed by fraudulent activity.
Filing an NYC Qui Tam Lawsuit
Just as anyone can become a victim of healthcare fraud, anyone can also report it by becoming a whistleblower. A qui tam lawsuit is a civil lawsuit where a third party (called a “relator”) brings an action against a wrongful party on behalf of the government. The government—not the person who sues—is considered to be the true plaintiff. If the case is determined to be valid, then the relator, or whistleblower, receives a share of the total amount awarded.
Becoming a whistleblower is the ethical and right choice to make. However, it can also be a financially rewarding one as well. Whistleblowers are eligible to receive up to 30 percent of the government’s total award in a successful qui tam lawsuit. In large cases of insurance fraud, this amount can end up being thousands or even millions of dollars.
A common example of a healthcare fraud whistleblower case in NYC might look like this: A healthcare administrator realizes that the practice she works for is double billing both Medicaid and the patient for the services that they provide. This results in the office receiving an inflated amount of money unlawfully.
After realizing this, the administrator has the option to come forward and report what is happening. If she does so and has enough information to back up her claim, she can file a qui tam lawsuit. In this suit, the administrator would be considered the relator. The government, on behalf of Medicaid, would be considered the plaintiff. If the practice is found guilty and ordered to pay a financial award, the administrator becomes eligible to receive a percentage of the total award paid by the practice. Often the amount the relator can receive is anywhere from 15 percent to 30 percent of the total amount recovered.
Common Warning Signs of Healthcare Fraud in NYC
Because of the complexity of the insurance and billing process, it can be difficult to be sure if the concerning activity you have noticed is actually fraudulent or not. According to the New York State Attorney General, there are several common warning signs of healthcare fraud in New York City.
- Running a Medicaid “mill”: Creating or operating a healthcare practice that does not serve a genuine need in the community, and exists only to bill Medicaid for fraudulent services.
- Billing for medically unnecessary services: This unethical practice can also put vulnerable patients at risk.
- “Double billing”: In this practice, a healthcare provider might bill both the patient as well as Medicaid, or Medicaid as well as a private insurance company directly for the same procedure. In other iterations, multiple providers might all bill Medicaid for the same patient’s procedure.
- Kickbacks: Financial arrangements between providers and pharmaceutical companies is another example of healthcare fraud. This may result in patients being prescribed medications or medical devices that are not in their best interests in order to ensure a higher payout.
- “Upcoding”: This practice entails billing Medicaid, Medicare, or the VA for more expensive procedures than the ones actually offered to patients.
- “Overbilling“: In medical procedures billed by the hour, such as home health visits, some providers will falsely inflate timesheets in order to bill for more care than was actually given to patients.
Blowing the Whistle: Your Rights in NYC
As a whistleblower, you may be concerned about retaliation and your own rights in a healthcare fraud case. However, there are certain whistleblower laws that protect those who come forward with information against retaliation. Whistleblower rights are heavily protected in the U.S., with laws in place prohibiting your workplace from firing you, reducing your pay or hours, or engaging in discriminatory practices against you should you step forward as a whistleblower.
Furthermore, our attorney consultations are kept confidential, and what you share is protected under attorney-client privilege. Speaking with an experienced whistleblower attorney at Tycko & Zavareei LLP is a safe first step to learning more about what you can do if you have knowledge or suspicions of healthcare fraud.
Contact Tycko & Zavareei LLP
Schedule a no-cost consultation with the experienced law team of Tycko & Zavareei LLP today to understand if a qui tam lawsuit is your best step forward to stopping healthcare fraud and wrongdoing in NYC. Contact us today to find out how we can help.
