Healthcare Fraud

August 8, 2016

Charges in an Allegedly Massive Scheme Highlight the Danger of Medicare Fraud

Is Medicare fraud really that big of a problem? After all, doesn’t fraud exist in almost every sector of the economy? Why focus so much energy on one issue? As recently filed charges in one case show, Medicare fraud is an enormous problem that costs our government billions of dollars every year. Stealing from the government is, in essence, stealing from every single taxpayer. Medicare fraud diverts money from those who truly need and deserve health care services and puts the money in the pockets of wrongdoers. At the same time, there is also very specific, personal harm to patients whose providers are involved in fraudulent schemes, patients whose health is put in jeopardy because a provider puts profit over care.

DOJ Announces Allegations of Fraudulent Medicare Billing in Excess of $1 Billion

Late last month, Assistant Attorney General Leslie R. Caldwell publicly announced the unsealing of charges in what she called “the largest single criminal health care fraud case ever brought against individuals by the Department of Justice.” The case involves allegations of fraudulent billing that total over $1 billion. The allegations are focused on a group in South Florida, a region particularly hard hit by Medicare fraud.

July 18, 2016

Medicare Fraud Spotlight: False Claims Act Lawyer on the Threat of Hospice Care Fraud

by Gregory J. Brod

Anyone who has ever watched a loved one fight through the final stages of a terminal illness knows how important kindness is during these times. Some of the kindest and most caring people in the world work with terminal patients and their families in hospice care settings. On behalf of everyone these people touch, we want to say thank you. It is because we respect these workers so much and understand the importance of their work that we are particularly angered by the allegations in a recent false claims act case accusing a health care provider of hospice care fraud. This case is a reminder of the very profound real world impact of health care fraud and it is one example of why we choose to serve as a health care fraud whistleblowers’ law firm.

Hospice Provider to Pay $18 Million to Settle Medicare Fraud Allegations

On July 13, the Department of Justice (“DOJ”) issued a press release announcing that a hospice care provider has agreed to pay $18 million to settle pending allegations of False Claims Act violations. The defendant, Evercare Hospice and Palliative Care (“Evercare”), now known as Optum Palliative and Hospice Care, is based in Minnesota and provides hospice care in several different states. As the DOJ explains, hospice care is a special form of care aimed at providing comfort to the terminally ill. Hospice care patients receive palliative care only and do not receive medical care aimed at treating their illnesses. Medicare only allows patients with a life expectancy of six months or less to receive coverage for hospice care.

July 11, 2016

Trends in False Claims Act Litigation: Individual Liability

by Gregory J. Brod

Regular readers of this blog know that part of what makes the False Claims Act such a powerful tool is its qui tam provision which allows individuals to bring claims for repayment on the government’s behalf. This is important because the government cannot police every single claim it pays and individuals who witness fraud and act on that knowledge are critical to the fight against fraud. A recent trend in litigation under the Act involves individuals in a very different sense – individual liability under the False Claims Act. Our whistleblowers’ law firm for fraud on the government is watching this trend and is prepared to help honest individuals fight fraud committed by both organizations and individuals.

DOJ Focuses in on Individual Liability for Corporate Wrongdoing

At the beginning of the year, Becker’s Hospital Review, a leader in healthcare industry information, published a piece entitled “5 False Claims Act Trends, Cases that will Fuel Recoveries in 2016.” One of the trends identified in this article is a “spotlight on individual liability” whereby the government is increasingly holding individuals, not just the companies they work for, liable for fraud. This stance grows, in part, out of a Department of Justice (“DOJ”) memorandum issued in September 2015 that discusses steps the DOJ is taking to increase legal accountability for individual corporate wrongdoing. One change announced in the memo is that corporations will only receive credit for cooperating with an investigation if they reveal the names of the individuals involved in the fraud.

June 27, 2016

The Escobar Decision: Whistleblowers’ Law Firm Applauds a Major Ruling from the Supreme Court Interpreting the False Claims Act

by Gregory J. Brod

The False Claims Act (“FCA” or “the Act”) is a powerful tool that allows private citizens to play a key role in fighting fraud on the federal government. As we have reported in previous blog posts, this term the Supreme Court agreed to look at a disagreement among appellate courts regarding the issue known as implied certification. Our whistleblowers’ law firm is pleased to report that the Court recently released a decision that affirms and strengthens the Act, ensuring it is available to fight a wide range of fraudulent acts.

Background: The Implied Certification Theory and the Escobar Case

As explained in The False Claims Act: A Primer, a guide released by the Department of Justice (“DOJ”), a person violates the FCA when they knowingly submit a false claim for payment to the government, knowingly cause another to submit a false claim, or knowingly create a false record/statement in order to induce the government to pay a false claim. The Act was originally passed during the Civil War. It underwent substantial revisions in the 1980s and again in 2009 and 2010.

June 13, 2016

Pharmaceutical Company Fraud and the False Claims Act

by Gregory J. Brod

Few decisions are as important as those regarding our health and the health of our loved ones. Decisions about medications, like many other health-related issues, involves a weighing of risks and benefits. With increased direct-to-consumer advertising and pressure on doctors from corporations, this calculus can be extremely hard. Americans must be able to trust that information released by pharmaceutical companies is accurate. In some cases, pharmaceutical company fraud can amount to a violation of the False Claims Act which means ordinary Americans have the power to fight back with the help of our health care fraud law firm.

Settlement in Suit Alleging Pharmaceutical Companies Misled Doctors and Others About Cancer Drug

On June 6, the Department of Justice (“DOJ”) announced that Genentech Inc. and OSI Pharmaceuticals LLC will collectively pay $67 million to settle allegations the companies made misleading statements about the drug Tarceva. A lawsuit filed under the False Claims Act alleged that, from 2006 through 2011, the companies made misleading representations to medical care providers about Tarceva’s ability to treat certain non-small cell lung cancers. In actuality, according to the DOJ, there was little evidence that Tarceva could treat these cancers unless a patient had never smoked or had a particular mutation in their epidermal growth factor receptor.

May 30, 2016

Understanding the False Claims Act: Whistleblowers’ Law Firm Looks at Government Intervention

by Gregory J. Brod

The False Claims Act is a powerful weapon and, as we’ve talked about on this page numerous times, a large part of that power comes from the fact that ordinary citizens can use it to fight many forms of fraud on the United States government. After the initial filing of a whistleblower fraud claim, the government will eventually decide whether or not to intervene in the case. This is an important part of the process and our whistleblowers’ law firm knows that intervention in False Claims Act cases, such as recently occurred in a health care fraud suit, is often a positive sign. However, it is important to know that claims can be and are successful even absent government intervention.

The FCA and Intervention Generally

The False Claims Act (“FCA” or “the Act”) is a Civil War Era statute that was reenergized by a series of amendments in the 1980s. In short, a company or individual violates the Act when it defrauds the government, typically by overcharging the government or a government agency. Under 31 U.S.C. §3730(b), private citizens are given the power to bring FCA claims on the government’s behalf. These whistleblowers, also known as relators, are crucial since fraud by its nature is secretive and the government could not effectively fight fraud without the assistance of individuals who witness fraudulent acts. After the suit is filed, the government investigates the claim and then the Department of Justice (“DOJ”) decides whether or not it wants to take over the case. The decision to do so is known in legal circles as intervention.

May 16, 2016

Using the False Claims Act to Protect Funds for Cancer Patients

by Gregory J. Brod

Cancer. Rarely can one word strike so much fear. We have come so far in both cancer prevention and cancer treatment; yet we also have so much farther to go before we can truly say we’ve triumphed over this massive beast. One major challenge is the cost of treating cancer. While much of that cost is due to the challenges of medical research, some companies are deliberately over-charging cancer patients and their insurance providers by billing for expensive and unnecessary services. The battle against cancer treatment fraud is yet another example of a front in which the False Claims Act can be a tool for justice and even a tool for health. As a health care fraud law firm, we partner with whistleblowers to fight these wrongs and ensure health care funds are available for true medical needs.

Company Pays Nearly $34.7 Million to Settle Allegations of Overbilling for Cancer Treatment

Earlier this Spring, the Department of Justice (“DOJ”) announced that 21^st Century Oncology agreed to pay nearly $34.7 million to settle a False Claims Act lawsuit alleging they performed and billed federal health care agencies (e.g., Medicare, Tricare, Medicaid) for procedures that were not medically necessary. The underlying suit involved a procedure called the Gamma function which measures the exit dose radiating from an individual after radiation treatments. The government alleged that the company performed and billed for this procedure when it was not needed for any medically appropriate purpose. Additionally, the suit alleged that 21^st Century billed for Gamma function treatments in cases where no physician reviewed the results in a timely manner and in cases where technical equipment failures meant no results could be obtained. The suit was originally brought by a former physicist with a Florida oncology company who filed the claims under the whistleblower or qui tam provisions of the False Claims Act and who will receive over $7 million for his role in the case.

May 9, 2016

The False Claims Act: What it Does and How Private Whistleblowers Can Use It

by Gregory J. Brod

We talk a lot about the False Claims Act (“FCA” or “the Act”)) on this blog. We do that because it is a powerful tool that allows ordinary Americans to take a stand and fight fraud. The frauds it fights are frauds perpetrated against the government and government programs, frauds that are ultimately crimes against the American people. Our posts often look at specific cases involving alleged violations of the FCA, but from time to time our whistleblowers’ law firm likes to take a step back and look at the FCA more generally to help our readers understand exactly what kind of wrongs the FCA tackles.

“A False or Fraudulent Claim”

The FCA is actually several sections of the United States Code, with 31 U.S.C. §3729 containing the basic description of what actions violate the Act. Although it is only one of a number of subsections that describe these actions, §3729(1)(a) explains the basic wrong the Act tackles “a false or fraudulent claim for payment or approval.” Essentially, this means that a person or entity is liable under the Act if they ask the government to pay an obligation that is not actually due or ask for more money than they are actually due.

May 2, 2016

Another Major Settlement in a Pharmaceutical Industry Health Care Fraud Case

by Gregory J. Brod

We can tell you that the False Claims Act is a powerful tool for fighting the growing epidemic of health care fraud in the United States. We prefer, however, to show you by citing some of the biggest verdicts and settlements in the field. This week, we highlight a settlement involving allegations of Medicaid fraud in the pharmaceutical industry. As a Medicare and Medicaid fraud whistleblowers’ law firm, we help honest witnesses bring lawsuits in cases like this one to fight back against pharmaceutical company fraud and other cases of fraud against government health care programs.

Drug Company to Pay $784.6 Million to Settle Claims It Failed to Report Accurate Pricing Data and Underpaid Medicaid Drug Rebates

On April 27, the Department of Justice (“DOJ”) issued a press release announcing that Wyeth and Pfizer (Pfizer acquired Wyeth after the alleged conduct ended; defendants referred to collectively as “Wyeth”) have agreed to pay $784.6 million to settle a False Claims Act suit alleging Wyeth committed Medicaid fraud by reporting false prices on two of its medications. The complaint alleged that Wyeth gave thousands of hospitals deep discounts on two protein pump inhibitor drugs but failed to report these lower prices to the government. Allegedly, Wyeth used a bundled sales agreement to induce hospitals to purchase two of its drugs and place them on hospital formularies. The government believes Wyeth sought to control the hospital market in part because patients often stay on the drugs for a long time after discharge and payers, including Medicaid, would then end up paying nearly full price for the medications.

April 11, 2016

Health Care Fraud Spotlight: Medicaid Fraud in the Dental Field

by Gregory J. Brod

Health care fraud touches almost every part of the American health care system and dental care is no exception. While dental services are typically not covered by Medicare, Medicaid requires states to include dental care for covered children and states can elect whether or not to cover dental care for Medicaid-covered adults. When dental fraud targets Medicaid dollars (or other government programs such as Tricare), children and adults can be deprived of an important aspect of overall health and taxpayer money is diverted from its intended purpose. Our dental fraud law firm works with whistleblowers using both state and federal False Claims Acts to bring the perpetrators to justice.

Two Examples of Medicaid Fraud Allegations Involving Dental Services

In February, according to a press release from the Department of Justice, a Missouri dentist entered a guilty plea to allegations he conspired to commit Medicaid fraud and to collect over $167,000 in connection with claims for orthodontic devices purchased for child patients in his dental clinics. In his plea, the dentist admitted he and his co-conspirators billed Medicaid claiming the devices were intended as a form of speech aid prosthesis when they were actually a method of straightening teeth without the use of braces. Although the Medicaid code used meant the claims were pre-certified, they should have been filed under a different code which would have required pre-authorization. In his plea, the dentist admitted the patients had not received and did not qualify for orthodontic treatment so Medicaid would not have covered the claims. The defendant further admitted that the co-conspirators paid around $50 per device, but billed Medicaid for approximately $695 per device (the maximum allowed for a speech prosthesis).