Healthcare is big business in the United States, with costs approaching 18 percent of the country’s gross domestic product. Government healthcare programs make up a hefty portion of these costs, with Medicare and Medicaid insuring nearly one in three Americans (over 100 million people).
The large amount of money at stake in the healthcare industry makes it a field day for fraudsters, with up to 10% of government healthcare spending lost to fraud. The government cannot possibly ferret out all of the fraud by itself, which is why courageous whistleblowers, with assistance from a skilled healthcare fraud attorney, have been the driving force behind the government’s successful prosecution of healthcare fraud.
Although much of the focus is on Medicare and Medicaid, whistleblowers with a healthcare fraud attorney can bring False Claims Act suits for all government-funded healthcare programs, including the TRICARE (military), Federal Employee Healthcare Benefits, and Veterans Administration programs.
What is healthcare fraud?
Healthcare fraud involves intentionally deceiving or misrepresenting information in healthcare transactions to gain unauthorized benefits. It targets government programs like Medicare and Medicaid, private insurers, or individual patients. The U.S. government has made healthcare fraud a major enforcement priority, primarily under the False Claims Act (FCA), a powerful tool to combat fraudulent schemes in the healthcare industry.
Common types of healthcare fraud we handle
Billing for services not rendered
An example of this type of false claim is the doctor who fraudulently bills the government for the impossible feat of 70 half-hour patient visits in a single day or the practice that routinely tacks on a certain billing code without performing the associated procedure because they know it will always be paid.
Upcoding
One of the most common False Claims Act violations, upcoding occurs when the facility or provider fraudulently bills the government using incorrect billing codes that result in a higher reimbursement than the correct billing code.
For example, a surgeon who performs a simple procedure but bills for an expensive, complicated surgery; a dentist who pulls one tooth but bills for three; a hospital that submits a false diagnosis that pays more; or an ambulance company bills a routine transport as emergency services.
Billing for medically unnecessary services
Examples of this type of False Claims Act violation are a doctor billing for cancer treatments for a patient who does not have cancer; a facility admitting patients who do not meet admission criteria, or a pain management doctor who over-prescribes procedures and medications.
Anti-Kickback Statute (AKS) violations
An example of an Anti-Kickback Statute violation is when a hospital refers patients to a provider or a provider prescribes a certain medication in exchange for some form of compensation, such as cash, trips, etc.
Kickbacks can be very creative, so the question is whether a provider is getting something for nothing that may be influencing their medical decision-making.
Compound drug fraud
Compounding pharmacies prepare unique prescription drugs to meet the needs of individual customers. For example, if an elderly patient cannot swallow, a compound pharmacy may crush her pills into a paste.
One example of this type of fraud is when the compounding pharmacy markets to patients who do not need the specialized formula, which can result in both unlawful kickbacks and prescriptions that are not medically necessary.
Generic drug substitutions
Pharmacies sometimes dispense a generic drug in place of the brand name drug on the patient’s prescription to get a better reimbursement rate from the government. Billing government healthcare programs for these substituted drugs can violate the False Claims Act.
Additional healthcare fraud cases we handle
Stark Law violations
An example of a Stark Law violation is when a doctor refers patients to a facility that she owns unless a “safe harbor” exception applies. Understandably, a doctor who makes money with every referral is likely to make more referrals, resulting in unnecessary procedures. The Stark Law prevents that from happening. Contact a healthcare fraud attorney if you suspect a Stark Law violation.
Bundling and unbundling
“Bundling” occurs when a provider bills the government for a panel of tests or procedures when only a single test or procedure was performed. “Unbundling” occurs when instead of billing for a single code that includes all the services provided, a provider breaks the billing up into separate codes to increase their reimbursement.
Falsified cost reporting
Hospitals submit annual cost reports to the government, which in turn affects how much Medicare will reimburse its patients. A hospital that knowingly submits a cost report with incorrect data resulting in additional government reimbursement may be liable for a False Claims Act violation.
False certifications
An example of a False Claims Act case based on false certifications is when a provider certifies that it has performed certain prerequisites or that the patient has certain conditions that qualify them for a procedure. Another standard certification on every Medicare claim is that the provider did not provide a kickback for the referral in violation of the Anti-Kickback Statute.
“Ghost” patients
In this type of False Claims Act violation, the government is billed for a service, treatment, test, device, or drug for a non-existent patient or a patient who never received the service or item.
Use of non-approved products
Providers may try to earn an extra buck by using non-approved or adulterated products, such as drugs and medical devices imported from foreign countries, but billing for the regular product. This not only is clear-cut billing fraud, but it puts patients at risk.
Incident to or split/shared billing fraud
Medicare permits midlevel providers (nurse practitioners and physician assistants) or staff to perform certain services and have them billed under a supervising physician, who pays a higher amount. But if there is no physician present or they are not involved in the patient’s care, such billing may be fraudulent.
Off-label marketing
Off-label marketing happens when pharmaceutical companies market their drugs to doctors for non-indicated uses, usually to increase drug sales. False claims result if this marketing causes doctors to submit claims to the government for these off-label drug uses. A Medicare fraud whistleblower can help reduce the hundreds of millions of dollars of fraudulent submissions to Medicare and Medicaid.
“Best price” fraud
These false claims arise from the violation of Medicaid rules requiring pharmaceutical manufacturers to give the government the lowest price for any purchaser. Ways that pharmaceutical manufacturers commit fraud include concealing the actual best price or by pricing deals between pharmaceutical companies and favored customers, such as chain drug stores.
“Marketing the spread”
By fraudulently inflating the price of a drug so Medicare and Medicaid over-reimburse for a drug, a pharmaceutical manufacturer can “market the spread,” i.e., promote the difference to a pharmacy. That pharmacy now has a financial incentive to dispense that drug versus its competitors. This is a violation of the Anti-Kickback Statute and should be discussed with a healthcare fraud attorney.
Defective medical devices
Sometimes medical device companies allow a medical device that they know or have reason to believe is defective to be put on the market. Government healthcare claims submitted for these defective devices may result in False Claims Act violations.
Fraud on the FDA
Medical device companies may be liable under the False Claims Act for lying or omitting information the FDA requires to approve their medical devices.
The False Claims Act and its role in healthcare fraud enforcement
The False Claims Act (FCA) (31 U.S.C. §§ 3729–3733) is the federal government’s main tool to combat healthcare fraud, allowing the government to pursue those submitting false claims for payment. It includes a qui tam provision, enabling whistleblowers to file lawsuits on the government’s behalf. Violators face treble damages (three times the fraudulent claim amount) and per-claim penalties. Whistleblowers are incentivized with a share of the recovered funds, ranging from 15% to 30%.
Our healthcare fraud attorneys serve clients nationwide
Our FCA attorneys represent whistleblowers across the U.S., handling cases at both the federal and state levels.
Federal level
Since federal funds support most healthcare programs, including Medicaid, healthcare fraud cases are often filed in federal court under the FCA, which is generally more favorable due to judges’ experience with FCA claims.
(H4) We come to you
We can be admitted to every federal court in the country in one of two ways. First, just because Jason and Julie live in Georgia does not mean they cannot be admitted to practice in other districts. For example, they are permanently admitted to practice in federal courts in Colorado, Michigan, and Tennessee.
Other courts only let local attorneys become permanent members, but they can grant special admission to out-of-state lawyers to enter an appearance on a case-by-case basis (making an appearance pro hac vice).
(H4) No charge for local counsel
In those instances where we appear in courts outside of Georgia, we usually bring on an additional law firm to act as local whistleblower counsel. These are attorneys who more regularly practice in the geographic area, and so have better knowledge of the judges and local rules that we will be operating under.
When we decide to incorporate local counsel, there is no charge to our clients; they share in our fee. So, our clients benefit from the False Claims Act expertise of our firm as well as the additional experience and manpower of our local counsel.
State level
Some states have their own False Claims Acts for Medicaid fraud. While these can be filed in state court, federal court is typically preferred. Filing in federal court allows for the recovery of both federal and state portions of the claim, maximizing potential whistleblower rewards.
Non-Medicaid state healthcare fraud
For non-Medicaid fraud cases involving state funds, lawsuits are filed in state court under relevant state False Claims Acts. Experienced whistleblower attorneys are essential, as state courts and judges may lack familiarity with these statutes.
Just about anyone in the healthcare arena can be found guilty of fraud
A dizzying array of people and entities can commit healthcare fraud. Whistleblowers who contact a medical fraud attorney can expose them via a False Claims Act complaint.
- Healthcare facilities, including hospitals, clinics, long-term care facilities, inpatient rehabilitation facilities, and laboratory/diagnostic testing facilities
- Healthcare providers, including physicians, therapists, and hospice providers
- Pharmaceutical organizations, including retail, compound, or long-term care facility pharmacies, pharmaceutical manufacturers and distributors, and medical device manufacturers and distributors
- Government contractors, including group purchasing organizations, Medicare Advantage Plan providers, and electronic health records software providers
How long does it take to be rewarded for a healthcare fraud case?
The timeline for healthcare fraud cases varies greatly, making it impossible to predict the duration, even for experienced attorneys.
Ballpark estimate
A straightforward case may settle in 2-3 years, while more complex cases can take longer. If the case is found unviable, this decision may come much sooner.
Why cases take so long
Investigations are thorough, requiring a detailed review of evidence to prove when and how fraud occurred. Even simple cases involve file-by-file reviews to ensure accuracy, and the government takes its time to ensure a strong case.
Settlement process and trial
Settlements may occur at any point, but litigation can take years. Motions and court delays add to the timeline.
Whistleblower reward negotiations
After settlement or judgment, the whistleblower negotiates their share (15-30%), which may require additional court involvement if an agreement isn’t reached.
First-to-file exception
Only the first whistleblower to file a claim is entitled to a reward, but determining who filed first can delay payment for months or even years if disputed.
A healthcare fraud attorney is ready to help
Whether you are in the contiguous 48 states, Hawaii, Alaska, or even Guam or Puerto Rico, we can handle your federal or state healthcare fraud case for you. Contact us online or call (770) 988-5035 today.
