October 5, 2023. The United States Department of Justice announced a settlement with Genomic Health, Inc. (GHI), a healthcare corporation specializing in genomic-based clinical diagnostic tests. The genetic testing company agreed to pay $32.5 million to resolve allegations of healthcare fraud relating to improperly manipulating Medicare’s 14-Day Rule. Two whistleblowers reported this fraud scheme and filed separate qui tam actions, which are both addressed in this settlement. One of the whistleblowers will receive over $5.6 million or 17.5% of the settlement. This case underscores the immense importance of healthcare fraud whistleblowers in safeguarding both patients and taxpayer dollars.
What Happened in this Healthcare Fraud Whistleblower Case?
The genetic testing company allegedly violated the False Claims Act through a nationwide scheme that lasted for 12 years. The allegations centered around GHI’s manipulation of Medicare’s 14-Day Rule, which governs the billing of genomic laboratory tests such as their main test, Oncotype DX®.
Under this rule, laboratories could not separately bill Medicare for covered tests if a physician ordered the test within 14 days of a patient’s discharge from a hospital stay. Instead, these tests should have been included in lump-sum payments made to hospitals or billed to the hospital for subsequent reimbursement by Medicare. GHI allegedly evaded this rule through several tactics, including seeking direct reimbursement for claims inside the 14-day window, and encouraging providers to cancel and reorder tests so the tests would occur outside the 14-day window. Additionally, the genetic testing company ran afoul of the Anti-Kickback Statute by intentionally delaying their invoices to hospitals past the 14-day window and simply writing off unpaid laboratory services fees.
The Role of Healthcare Fraud Whistleblowers
The Genomic Health, Inc. case was brought to light thanks to whistleblowers who filed actions under the qui tam provisions of the False Claims Act. These provisions allow private individuals to file actions on behalf of the United States when they have knowledge of fraudulent activities. In return, whistleblowers may receive a portion of any recovery, as was the case here, with whistleblowers receiving a 17.5% share or $5,687,500.
Why Healthcare Fraud Whistleblowers Matter
1. Protecting Patients:
Whistleblowers play a pivotal role in safeguarding patient well-being. In this case, the alleged fraud delayed crucial cancer diagnostic tests for patients. By exposing such misconduct, whistleblowers help ensure timely and accurate healthcare services, potentially saving lives.
2. Preserving Taxpayer Dollars:
Healthcare fraud places a significant financial burden on taxpayers. Whistleblowers help recover funds that can be paid out to providers with legitimate claims, benefiting society as a whole.
3. Upholding Healthcare Program Integrity:
Healthcare providers must adhere to rules and regulations designed to maintain the integrity of government-funded healthcare programs, such as Medicare, Medicaid, and TRICARE. Whistleblowers act as watchdogs, holding organizations accountable for their actions and deterring fraudulent behavior.
4. Empowering Whistleblowers:
Whistleblower protections encourage individuals to come forward with information about wrongdoing without fear of retaliation. This empowers them to act as ethical guardians within their organizations.
The Genomic Health, Inc. case serves as a powerful reminder of the vital role healthcare fraud whistleblowers play in our healthcare system. Their courage in exposing fraudulent practices not only safeguards patient well-being but also ensures the responsible use of taxpayer dollars. As we continue to combat healthcare fraud, whistleblowers remain a crucial asset in upholding the highest standards of healthcare integrity.
If you would like to report Medicare fraud including laboratory fraud, you can contact attorneys at Tycko & Zavareei LLP. Eva Gunasekera and Renée Brooker are former officials of the United States Department of Justice and prosecuted whistleblower cases under the False Claims Act. Eva was the Senior Counsel for Health Care Fraud. Renée served as Assistant Director at the United States Department of Justice, the office that supervises False Claims Act cases in all 94 United States District Courts. Eva and Renée now represent whistleblowers. For a free consultation, you can contact Eva Gunasekera at [email protected] or contact Renée at [email protected] (tel.: 202-417-3664). Visit Tycko & Zavareei LLP’s website for whistleblowers to learn more at www.fraudfighters.net.