CareCore National, LLC and the U.S. Department of Justice entered into a settlement agreement, according to a May announcement. CareCore will pay $54 million to resolve a False Claims Act suit based on allegations it fraudulently billed government insurance programs. The business provides pre-authorization/pre-certification services to managed care plans. It determines whether diagnostic testing is medically reasonable and necessary for patients and should be paid for by health insurers. However, the allegations brought by a previous employee stated that CareCore did not follow its protocol and directed nurses to move forward with medical services that were not reviewed or medically necessary. This caused hundreds of thousands of inappropriate and unnecessary diagnostic tests to be approved and billed to Medicare and Medicaid.
Why the Whistleblower Came Forward
CareCore’s previous employee, John Miller, a licensed practical nurse, filed the qui tam suit against the business on behalf of the government. Miller acted as a clinical reviewer for the company and was required to assess whether a medical procedure met certain criteria for being approved. If the service was necessary and appropriate, it would be submitted to the insurance company for payment. Due to the high demand for its services, CareCore could not keep up. In response to the demand, it created the program known as Process As Directed (PAD). Through this program, clinical reviewers like Miller automatically approved prior authorization requests without a physician performing an independent review. This enabled CareCore to return more pre-authorization requests in a shorter period of time. PAD ultimately led to more than 200,000 deceptive authorizations between 2005 and 2013. Medicare and Medicaid paid for many of these unnecessary and fraudulently approved tests.
Whistleblower to Receive Millions
While whistleblowers often have noble reasons for coming forward, they also have a financial incentive. If the government successfully obtains compensation based on the qui tam suit, then the whistleblower is entitled to a portion of this settlement or jury award. They usually receive 15 to 25%. For the CareCore settlement, Miller may receive up to $10.5 million. This rewards Miller for his bravery in coming forward with information regarding fraud against the government and compensates him for his time in this case, which was filed in February 2013. He has had to participate and wait for an outcome for this case for more than four years.
Do You Have Information About Healthcare Fraud?
Considering the complexities and apparent loopholes in our insurance system, it is no surprise that the healthcare industry is one of the leading areas for False Claims Act cases and where the federal government recovers a great deal of money for fraud. However, the states and federal governments would not be successful in recovering unlawfully obtained and retained money if it were not for individuals willing to step forward with information and evidence. If you believe your employer is fraudulently billing Medicare or Medicaid, it is time to speak with an attorney experienced in qui tam suits.
The healthcare fraud lawyers of Brod Law Firm can review your situation, advise you on your rights, and let you know your options. Call us today at (800) 427-7020 to schedule a free consultation.
(image courtesy of Daniel Frank)