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Overbilling, Upcoding, Unbundling, Excessive Billing

Many medical procedures and supplies are billed to Medicare, Medicaid, TRICARE, VA, or FEHB based upon “codes.”  For example, office visits and medical procedures are often billed based upon what are known as CPT (Current Procedural Terminology) Codes.  We have seen instances where a health care organization or provider delivers a particular health care service to a patient but uses a more expensive “code” when billing for the service.  This is known as “upcoding” and is a form of fraud.

Also, certain groups of related health care services or supplies must be “bundled” and billed under a single code.  However, a health care provider or organization can unlawfully obtain higher reimbursement from the health care programs by “unbundling” the services, and billing under multiple codes.  This is also a form of fraud.

These types of activities lead to Medicare, Medicaid, TRICARE, VA, or FEHB paying more money to health care organizations or providers than they are entitled to receive.

This is just another way to cheat taxpayers.  The Department of Justice is interested in hearing from individuals with knowledge of these types of fraudulent practices.

If you are aware of old, new, or evolving fraud schemes involving overbilling, upcoding, unbundling, or excessive billing, the Department of Justice may be very interested in learning more about the information you have.  You may also be entitled to a financial reward.  Tell us about the information you have. We will provide you a free consultation.

Opioids

The Department of Justice has investigated and resolved a number of important cases against pharmaceutical companies for their role in the opioid crisis.  We expect the Department of Justice to investigate other health care organizations and providers in the supply chain who contributed to the opioid crisis.

There are many players who may bear False Claims Act responsibility for the opioid crisis such as health care providers that put patients at risk because they were paid handsomely by the pharmaceutical industry to prescribe opioids.  Laboratories that churned out test results that put maximizing billing ahead of patient safety, or that use bundled tests or other fraudulent schemes to induce providers to bill for excessive drug tests.  Rehabilitation clinics that admitted and discharged addicted patients through a revolving door rather than provided effective treatment options.  Drug insurance plans that covered opioids with no prior authorization.  Pharmacy benefits managers—the middlemen—that made access to opioids easier than less addictive alternative remedies.

Holding these health care organizations and providers accountable requires that knowledgeable insiders come forward.  There are anti-retaliation laws to protect whistleblowers who provide tips and helpful information to the government.

According to the Centers for Disease Control (CDC), well over one-half MILLION people have died from opioids.

The Department of Justice has used information and tips from individuals to pursue health care providers and organizations that contributed to the opioid crisis.

For example, one drug company admitted that it engaged in illegal conduct by promoting a prescription drug that was a powerful opioid painkiller.

Specifically, the drug company agreed to pay $225 million to resolve its criminal and civil liability for paying kickbacks and engaging in other unlawful marketing practices.  The kickbacks included employment, lavish meals, and entertainment for the relatives and friends of the physicians who prescribed the drugs.  The Department of Justice also alleged that the company improperly encouraged physicians to prescribe the drug for patients who did not have cancer and lied to Medicare and TRICARE about the patients’ cancer diagnoses.

Several individuals who reported the fraud were entitled to receive a share of the $225 million settlement as qui tam relators because they provided helpful information to the Government to assist with the investigation.

The Department of Justice also recovered $1.4 BILLION from a global consumer goods conglomerate for fraudulently converting thousands of opioid-addicted patients over to another addictive opioid drug and causing state Medicaid programs to expand and maintain coverage of this drug at substantial cost to the Government.  This case was also the result of individuals who reported the fraud to the Department of Justice.

Another $600 MILLION was also recovered from a related entity for fraudulent marketing of the opioid-addiction-treatment drug.  Again, this massive settlement was the result of numerous individuals reporting this fraud to the Department of Justice.

Further, a provider who owned pain management clinics in Kentucky and Georgia and performed medically unnecessary balance tests, nerve conduction procedures, and qualitative drug screens, paid $20 million under the False Claims Act. The three individuals who brought those allegations to the attention of the Justice Department were entitled to a share of the Government’s recovery of Medicare, TRICARE, and FEHB money.

If you are aware of old, new, or evolving fraud schemes involving opioids by pharmaceutical companies, healthcare providers, labs, rehab clinics, drug insurance plans, or pharmacy benefits managers, the Department of Justice may be very interested in learning more about the information you have.  You may also be entitled to a financial reward.  Tell us about the information you have.  We will provide you a free consultation.

Lab schemes

Individuals have also brought to the attention of the Department of Justice allegations that lab companies have performed tests that were medically unnecessary or paid kickbacks to other providers to refer patients for lab tests.

Fraud schemes involving labs or laboratories often involve Medicare, Medicaid, TRICARE, VA, or FEHB program overpaying for initial drug screens and confirmatory tests.

For example, it is unlawful to have a “standing order” that all patients have certain lab tests.  Health care providers are required to customize orders for lab tests such as confirmatory urine drug tests based on each patient’s individualized risk assessment and circumstances.

As for paying physicians for referrals, it is critical that patients can trust that decisions made by medical providers are based upon the best interests of their patients and not financially motivated.

Another testing lab company was required to pay $43 MILLION for performing unnecessary lab tests on patients and billing Medicare and TRICARE.

In this case, the individual who brought to light these allegations received a $6 MILLION share of the Government’s recovery.  Without the whistleblower, the Department of Justice would have been unaware of the fraud and the taxpayers would have continued to be cheated.

If you are aware of old, new, or evolving fraud schemes involving improper billing for lab tests, the Department of Justice may be very interested in learning more about the information you have.  You may also be entitled to a financial reward.  Tell us about the information you have.  We will provide you a free consultation.

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