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Types of Whistleblower Cases

Blowing the Whistle on Medicare Fraud, Medicaid Fraud, and Other Healthcare Fraud

If you have information showing that a healthcare provider has committed fraud on a government healthcare program, such as Medicare or Medicaid, then you may be able to bring a qui tam lawsuit under the federal False Claims Act or similar state laws. Through the qui tam lawsuit, you would help the government recover money that has been paid as a result of fraudulent claims. Federal and state governments have recovered billions of dollars as a result of information provided by qui tam whistleblowers in healthcare fraud cases, whether the fraud is committed by hospitals, nursing homes, pharmaceutical companies, DME suppliers or physician practices.

As your reward for blowing the whistle, you could receive a share of the government’s recovery. A healthcare whistleblower who brings a successful qui tam lawsuit will receive between 15% and 30% of the amount that the government recovers.

Healthcare providers who submit claims to the Medicare or Medicaid system must provide various types of information, and maintain certain specified records, in order to legally claim reimbursement. If a provider submits a claim for payment to which it is not entitled, or falsifies the documentation supporting the claim, then the provider may be violating the False Claims Act. Some common forms of Medicare and Medicaid fraud include the following:

Charging for Services or Supplies Not Provided

The most basic form of fraud that a provider can commit is to submit claims to the Medicare or Medicaid system for services or supplies that the provider did not in fact delivery to a patient or beneficiary.

Upcoding and Unbundling

Many medical procedures and supplies are billed to Medicare or Medicaid based upon “codes.” For example, office visits and medical procedures are often billed based upon what are known as CPT Codes. A common form of fraud is for a physician practice, hospital or other provider to provide a particular service to a patient, but to use a more expensive “code” when billing for the service. This is known as “upcoding,” and is a form of fraud.

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

We have seen both types of coding healthcare fraud cases.

Falsifying or Failing to Maintain Records

Generally, Medicare and Medicaid will only reimburse a provider for services or supplies if those services or supplies are medically necessary. Applicable regulations require providers to maintain (or in the case of DME suppliers, to obtain) various forms of documentation, such as doctors’ orders or notes, demonstrating medical necessity. If a provider or supplier either falsifies those records, or fails to maintain them as required by the regulations, then the provider or supplier may be committing fraud when it submits claims for payment to the Medicare or Medicaid system.

Off-Label Marketing by Pharmaceutical or Medical Device Companies

Pharmaceuticals and certain medical devices must be approved by the FDA before they can be sold to the public. Medicare and Medicaid regulations provide that reimbursement for pharmaceuticals and medical devices is only available when those pharmaceuticals or devices are used in the manner approved by the FDA. Companies that sell pharmaceuticals or devices, however, often unlawfully promote the use of their products for non-approved, or “off-label,” uses to increase profits. This off-label marketing leads to the submission of improper claims to the Medicare and Medicaid systems. Some of the largest qui tam cases ever – including some cases that have settled for more than $1 billion – arose out of such off-label marketing schemes.

Unlawful Kickbacks or Financial Arrangements

A number of laws, including the so-called Stark laws and Anti-Kickback laws, generally prohibit the giving of money or other financial incentives (such as gifts) to doctors or hospitals in exchange for referrals or for the prescription of particular pharmaceuticals or supplies. These rules are intended to assure that doctors and other healthcare providers make decisions for their patients based solely upon medical necessity, and not because of some unlawful financial gain. Violations of the Stark and Anti-Kickback laws can result in false claims because, when a provider submits a claim to Medicare or Medicaid, the provider certifies that it has not violated these laws. Thus, if a healthcare provider is receiving kickbacks or is involved in an unlawful financial arrangement, the provider is also violating the False Claims Act, and could be subject to a qui tam lawsuit.

Cost Report Fraud

Hospitals and certain other types of healthcare institutions are required to submit “cost reports” to Medicare. These reports are used to calculate reimbursement rates under the Medicare programs. Accordingly, if a hospital manipulates its cost reports or falsifies the data in the reports, it can fraudulently obtain additional compensation. But doing so is a violation of the False Claims Act, and can give rise to a Medicaid or Medicare fraud whistleblower case.

Contact A Medicare Fraud Attorney

The qui tam attorneys of Tycko & Zavareei LLP are experienced in healthcare fraud investigations and litigation, and are here to help any Medicaid or Medicare whistleblower with a free, confidential, initial consultation. Contact us at 202-973-0900 today or fill out our form now for a free case evaluation.