Articles Tagged with attorney for health care whistleblowers

People make mistakes in the course of their job every day. When those ‘mistakes’ are intentionally made by a physician or health care billing administrator, though, they are considered fraud. The U.S. Department of Justice (DOJ) has spent the last few years cracking down on health care fraud, with the help of whistleblowers.

Billing and coding errors are the most common violations under the False Claims Act. The following are the most common ways those in the health care industry come to be under investigation by the DOJ.

Inaccurate Billing Codes

With about one-third of the cost of the healthcare industry in the U.S. lost to fraud, waste, and abuse, it is vitally important to society that we report healthcare fraud when we see it. While it is certainly helpful to familiarize yourself with the most common healthcare fraud schemes and pay close attention to all bills received from your healthcare provider, it is not always easy – or possible – to detect healthcare fraud with the naked eye. Thanks to technology and the development of big data, however, there are new and improved ways to detect healthcare fraud today that have never before existed. Below is a brief overview of how you can use big data to help combat healthcare fraud. If you believe you have witnessed healthcare fraud, contact one of our attorneys today to find out how you can report your claim and initiate a whistleblower lawsuit.

Common Types of Healthcare Fraud

The most common type of healthcare fraud is fraudulent billing. Healthcare providers may bill for services that were never rendered, or bill for a more expensive service than the one that was rendered. For example, a doctor might bill a patient for a two-hour visit when in fact the visit was only one hour long. Fraudulent billing in the medical space is so common that it accounts for up to 10% of annual healthcare costs in the U.S.

Ever since the passage of the Affordable Care Act in 2010, all violations of the Anti-Kickback Statute (AKS) have been actionable under the False Claims Act (FCA). In plain language, this means that, if you are aware that people in your workplace are defrauding government agencies, you can file a qui tam lawsuit, also known as a whistleblower lawsuit, on behalf of the government. California has become the most recent state in which the Department of Justice (DOJ) has taken legal action against a pharmaceutical company that, according to whistleblowers, engaged in fraudulent practices related to the marketing and promotion of an addictive drug.

The Drug, the Pharmaceutical Company, and the Fraudulent Activities

The drug at the center of the controversy is an analgesic mouth spray; the FDA has approved the drug only for the treatment of breakthrough cancer pain. Breakthrough pain, a phenomenon common in cancer patients, is when a patient is able to control his or her chronic pain through consistent use of medication but occasionally also suffers acute pain (“breakthrough pain”) that requires additional medication. Thus, the approved uses for the drug were quite narrow. Despite this, the pharmaceutical company allegedly engaged in several prohibited practices in order to entice physicians and nurse practitioners to prescribe the drug for patients other than those for whom it was intended. Whistleblowers reported the following AKS violations on the part of the drug company.

Alere, Inc. and its wholly owned subsidiary Alere San Diego agreed to pay the U.S. $33.2 million to resolve allegations that the medical device manufacturer violated the False Claims Act. (Alere was acquired by Abbott, one of the world’s largest healthcare companies, in October 2017.) According to the Department of Justice (DOJ) press release, Alere caused hospitals to submit inaccurate claims to Medicare, Medicaid, and other federal healthcare programs by willfully selling unreliable point-of-care diagnostic testing devices.

If you are aware of a company knowingly selling inaccurate medical devices, call a San Francisco healthcare fraud attorney at Brod Law Firm today.

Fraudulent Medical Devices Lead to False Claims

In March, the Department of Justice for the Eastern District of California announced the federal government and California reached a settlement agreement with Kmart. The retailer, based in Illinois with locations throughout California, will pay $525,000 to resolve allegations that it violated the federal False Claims Act by knowingly submitting false claims to Medi-Cal. The claims for reimbursement were not supported by appropriate diagnoses and documentation.

Kmart’s Fraudulent Billing

Medi-Cal uses a formulary list that designates restrictions for the drugs listed, known as Code 1 drugs. Certain restrictions are related to approved diagnoses. Medi-Cal will reimburse pharmacies for Code 1 drugs, but only if their use is in line with the formulary’s restrictions. For instance, a pharmacy may not be reimbursed for a drug prescribed and dispenses for an unapproved diagnosis.