Medicare Fraud Whistleblower / Medicaid Fraud Whistleblower
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The Medicare and Medicaid programs are particularly vulnerable to fraud, waste, abuse, and improper payments. In fact, in fiscal year 2010, the Centers for Medicare & Medicaid Services (CMS) estimated that these programs made more than $70 billion in improper payments. Whistleblower lawsuits are an extremely effective way to fight Medicare and Medicaid fraud, and these types of qui tam cases account for some of the largest False Claim Act monetary recoveries.
Examples of Medicare and Medicaid fraud eligible for False Claims Act whistleblower rewards include:
- Off-label promotion
- Payment of kickbacks to hospitals, doctors, nursing homes
- Billing for services not rendered
- Double billing
- Unnecessary medical treatment or services
- Upcoding and unbundling fraud
If you have first-hand knowledge of Medicare or Medicaid fraud, you may be eligible to file a whistleblower lawsuit on behalf of the U.S. government. The False Claims Act allows whistleblowers to receive anywhere from 15-30 percent of the government’s recovery in a qui tam lawsuit, and protects Medicare and Medicaid whistleblowers from retaliation for reporting fraud.
All prescription medications sold in the U.S. must first be approved by the U.S. Food & Drug Administration (FDA). Once approved for a particular indication, the manufacturers must market the drug for only that use. Medicaid and Medicare reimbursement is generally prohibited if the drug is not being used for a medically-accepted indication. A pharmaceutical company illegally “misbrands” a drug if the labeling, or any marketing and promotional materials relating to the medication, describes intended uses that have not been approved by the FDA.
Illegal off-label marketing can include any of the following activities:
- Providing training to pharmaceutical sales representatives about off-label uses and dosages (typically higher than the approved dose)
- Providing sales representatives with medical literature that endorses off-label uses
- Providing financial incentives or kickbacks to physicians in exchange for writing off-label prescriptions
- Paying physicians to promote off-label uses in speaking engagements or medical literature
When drug manufacturers promote their drugs off-label and persuade physicians to write off-label prescriptions to beneficiaries of Medicare and Medicaid, the company has caused the submission of false claims for reimbursement to the government.
Payment of Kickbacks
Pharmaceutical companies and medical device manufacturers are legally barred from paying physicians, hospitals and nursing homes kickbacks for using their products. Federal law further prohibits anyone from making or accepting payments to, or rewarding anyone for referring, recommending, or arranging for the purchase of items being paid for by federally funded programs. The federal Anti-Kickback statute prohibits cash payments, as well as in-kind rewards, such as free vacations, gifts and paid contracts. Healthcare providers must comply with the Anti-Kickback statute in order to participate in Medicare, Medicaid, and other federal health care programs. As such, claims for reimbursement of medical services that were related to kickbacks are false claims under these programs.
Billing for Services not Rendered
Billing for services not rendered is one of the most common forms of Medicare and Medicaid fraud. Such fraud could involve physicians billing Medicare or Medicaid for diagnostic procedures they never performed; physical therapists billing for sessions that never took place; and nursing homes billing for supplies that were never purchased or used. These cases often involve some falsification of records to support the improper billings.
Double billing occurs when a healthcare provider bills both Medicaid and the recipient (or private insurance) for the same service. Double billing fraud may also involve a case where two providers bill for the same service. For instance, providers may bill using an individual code and again as part of an automated or bundled set of tests.
Unnecessary Medical Treatment or Services
This type of fraud can encompass billing for services, drugs, supplies or equipment that were not furnished, or were of lower quality; calling a patient to come back to the provider’s office, even when it’s obvious additional appointments are not necessary; providing a set amount of services based on time and then billing for more time than was really provided; billing for office visits that didn’t actually occur; and substituting or misrepresenting items billed.
Upcoding and Unbundling Fraud
Medicare, Medicaid and other government insurance programs use a billing system known as CPT (current procedural terminology) coding. Every possible medical procedure has its own CPT code, and Medicare and Medicaid use these codes to pay providers a specific, agreed upon amount. For example, when a patient visits their doctor for a regular checkup, the visit would normally be reimbursed at $60 according to the checkup CPT code. Upcoding occurs when a provider performs a service and then bills Medicare via a CPT code for a higher paying service than what was performed.
Unbundling is another complex type of coding fraud. Also known as “fragmentation,” this involves submitting bills in a piecemeal fashion for tests and procedures that are required to be billed together under Medicare and Medicaid guidelines require that certain tests or procedures that are normally performed together be billed as a whole, rather than allowing individual reimbursement for each of the related services or tests. To facilitate bundling, billing codes have been established for batteries of related tests and procedures. However, separate billing codes also exist for each separate test/procedure in a battery. When billed separately, these procedures can easily exceed the normal Medicare or Medicaid reimbursement for the battery. Thus, the illegal practice of unbundling can artificially maximize reimbursement for a provider who engages in this fraud.
Learn More about Filing a Medicare, Medicaid Fraud Whistleblower
If you are considering becoming a Medicare or Medicaid fraud whistleblower, Alonso Krangle, LLP can help. We offer free legal evaluations to potential False Claims Act whistleblowers. Our whistleblower lawyers will review your case in detail, and ensure you comply with the detailed requirements of the False Claims Act. For more information, please fill out our online form or call 1-800-403-6191 today.