Articles Posted in Healthcare Fraud

hush-naidoo-382152-copy-300x200With the development of big data and predictive analytics, it is easier today than ever before to detect and prevent healthcare fraud. Gone are the days of lengthy, old-fashioned investigation, and here to stay are new technologies that can identify fraudulent activities automatically and instantly. By parsing through big data and analyzing payment trends, predictive analytics softwares can identify inconsistencies in payment and seemingly fraudulent activity. This article delves deeper into the system that mines data and predicts fraud by explaining the many components that make up a fraud detection software. If you are interested in learning more about how you can use technology to detect healthcare fraud, contact our attorneys today to learn more.

Link Analysis

Link analysis focuses on measuring relationships. It mines and analyzes data relating to how individuals, healthcare providers, healthcare employees, and healthcare suppliers are related to and interact with one another. It can identify unusual interactions and even unusual identities, such as multiple or fake addresses and phone numbers.

markus-spiske-666905-unsplash-copy-300x200With 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.

ken-treloar-385255-copy-300x200Medi-Cal fraud occurs more frequently than you think and often goes unnoticed. Unfortunately, this only harms recipients and future recipients of Medi-Cal who desperately need this healthcare assistance program in order to obtain the medical treatments they require. As a whistleblower, you have the opportunity to help put an end to Medi-Cal fraud by reporting healthcare providers and professionals who engage in fraudulent acts. If you detect any fraudulent acts by your healthcare provider, contact the healthcare fraud attorneys at Willoughby Brod today to learn more about how you should proceed with your whistleblower claim.

What is Medi-Cal?

Medi-Cal is a California Medicaid program for low income adults and children that is supported by both federal and state taxes. Those who qualify for Medi-Cal can receive free or low-cost healthcare services and generally receive the same benefits offered under Covered California but at much discounted or free prices. Anyone can apply for Medi-Cal regardless of age, sex, race, religion, sexual orientation, color, national origin, marital status, disability, or veteran status.

israel-palacio-463979-copy-300x200With the high number of TRICARE fraud cases in the United States, it is no wonder that healthcare fraud is the second highest priority of focus for the U.S. Department of Justice. The $2.7 trillion healthcare industry is an enticing target for those wanting to commit healthcare fraud, which is defined as purposefully misrepresenting a medical treatment or product in order to receive a higher benefit. In fact, Humana Military has estimated that 7-10% of the $2.7 trillion industry is fraudulent. If you suspect your doctor is committing TRICARE fraud, call an experienced qui tam lawyer at The Brod Law Firm today to learn more about how you can report your case as a whistleblower.

What is TRICARE?

TRICARE is a federal healthcare program, similar to Medicare, for uniformed service members, retirees, and their families. TRICARE provides comprehensive coverage to its beneficiaries, including general health plans, special programs customized for beneficiaries, prescriptions, and dental plans.

hush-naidoo-382152-copy-300x200Insurance fraud can take place across multiple industries, from automobile insurance to medical insurance to property insurance. In most cases, the victim does not even know that he or she has been defrauded. By making yourself aware of common insurance fraud schemes in California, you can better equip yourself to identify insurance fraud when it occurs and help stop insurance fraud in California. If you believe you have witnessed an incident of insurance fraud, call Brod Law Firm at (800) 427-7020 today to speak with an experienced qui tam attorney and learn how you can help.

What is Insurance Fraud?

The California Penal Code defines insurance fraud as the willful injury, destruction, or disposition of any property that is insured against loss or damage. Consumers and businesses alike can be guilty of insurance fraud. While a consumer might be found committing insurance fraud by submitting a claim to his or her insurance company based on false injuries, a business might be found committing insurance fraud by inflating the cost of their services or billing for services that were never performed. While insurance fraud can take place in just about any industry, the most common industries in which insurance fraud is seen are the automobile, healthcare, workers’ compensation, property insurance, and life insurance industries.

ken-treloar-385255-copy-300x200It is illegal in California to commit health care fraud, yet with the confusing payment bureaucracy for health care in the United States, health care fraud occurs more frequently than most people think. Health care fraud, also known as medical insurance billing fraud, health insurance fraud, Medicare fraud, Medi-Cal fraud, or HMO fraud, takes the form of many different types of improper and illegal actions. By familiarizing yourself with the most common types of health care fraud schemes, you may be able to identify if and when your health care provider is committing health care fraud. If you have information regarding improper billing or other types of health care fraud from your health care provider, call Brod Law Firm at (800) 427-7020 today to speak with an experienced health care fraud attorney and learn more about your rights and remedies today.

Seven Common Health Care Fraud Schemes

  1. Billing for services that were never performed

ken-treloar-385255-copy-300x200The False Claims Act (FCA), which prohibits entities that conduct business with the government from defrauding the government, goes all the way back to the time of the Civil War. It is sometimes called the Lincoln Law because of the president who was in office when the law went into effect.

Since the advent of Medicare and Medicaid, physicians and hospitals fraudulently obtaining payments from publicly funded healthcare programs have been defendants in many FCA lawsuits. Often the violation is not as simple as doctors submitting claims to Medicare for services they did not perform, although such fraudulent claims certainly do constitute FCA violations. Likewise, some FCA violations occur when doctors perform unnecessary procedures (for example, performing a surgery when the patient’s condition could be adequately managed with medication) just to be able to bill Medicare for them. It can even be an FCA violation if a doctor benefits financially from referring a Medicare or Medicaid patient for other services. If you are a healthcare worker and have evidence that your workplace has intentionally benefited financially from referrals made at the expense of Medicare or Medicaid, filing a qui tam lawsuit could offer you legal and financial protection while also protecting patients and taxpayers from fraud.

The Stark Law

jonathan-perez-409943-copy-300x200Ever 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.

ken-treloar-385255-copy-300x200Medicare and Medicaid are taxpayer-funded healthcare programs instituted for the purpose of ensuring that all Americans have access to basic health services. Fraud on the part of health care providers is a major threat to these programs and to the health of millions of Americans who benefit from their services. Every year, physicians and other members of the healthcare industry enrich themselves by diverting funds from Medicare and Medicaid to themselves and by fraudulently billing these publicly funded programs. Whistleblowers who have helped bring legal action against purveyors of healthcare fraud have helped the nation recover billions of dollars for healthcare.  If you are aware of healthcare fraud at your workplace, contact an attorney to discuss filing a qui tam lawsuit.

How Big a Problem is Healthcare Fraud?

The Department of Justice collects data on healthcare fraud, and the figures are alarming. For 2014, the most recent year for which the DOJ has published statistics, it is clear that healthcare fraud was widespread, but that the government, with the help of whistleblowers, was taking effective measures to stem it.

piron-guillaume-96228-copy-300x200Federal authorities arrested five individuals connected to San Fernando Valley clinics and a significant health care fraud scheme. On May 22, a federal grand jury indictment was unsealed. The indictment alleges that the five individuals engaged in a health care fraud conspiracy over multiple years and targeted at least eight health insurance companies and the International Longshore and Warehouse Union, the Pacific Maritime Association Benefit Plan, and the Federal Employees Health Benefits Program.

The Conspirators

According to the Department of Justice (DOJ) press release, the co-conspirators included: