Articles Posted in Healthcare Fraud

max-bender-262783-unsplash-copy-300x199On December 21, 2018, the Department of Justice released its statistics for Fiscal Year 2018 for actions taken under the Federal False Claims Act. The news release listed several notable cases and provided daunting statistics regarding the scope of fraud committed against the government in our country.

Federal False Claims Act

The Federal False Claims Act is a law that allows the government to go after both companies and individuals who file false invoices or claims in order to get paid by the government for services or products. The law also allows “relators” to recover from those who defraud the government as an incentive to citizens to help the government curb fraud and abuse in government programs.  Relators can receive up to 30% of the recovered proceeds through “qui tam” lawsuits.

jonathan-perez-409943-copy-300x200Every day we hear shocking news about the opioid epidemic, from the number of deaths from overdoses to the sheer amount of distribution arrests to the amount of money government is spending to combat the problem. One of the areas that the public may not know about, however, is how much of the problem is being created by dishonest health care professionals across the country through fraud and illegal practices.

The Opioid Epidemic

We are bombarded with statistics about the enormity of scope of opioid use in our country. For example, in FY2016, the Centers for Disease Control and Prevention (CDC) estimated that 42,249 Americans died from opioid overdose in our country.  The Substance Abuse and Mental Health and Services Administration (SAMSHA) estimates that 11.8 million Americans over the age of 12 have abused prescription opioids and heroin in the last year. The federal Department of Health and Human Services announced in September of this year that they have awarded over $1 billion in grants to “help combat the crisis ravaging our country.” Obviously, the problem is incredibly dangerous, incredibly real, and at the forefront of discussion in the US.  What is not as obvious is what role healthcare fraud plays in fueling this problem.

jonathan-perez-409943-copy-300x200A doctor was arrested on December 13, 2018 for improperly distributing opioids to his patients and billing Medicare for the drugs. The doctor now faces 45 federal charges relating to healthcare fraud for not only prescribing illicit drugs to patients but requiring those with insurance to accept injections so that he could bill additional costs to public health programs like Medicare. While this is an extreme example of pharmaceutical fraud, there are numerous smaller incidents of pharmaceutical fraud that take place every day. If you believe your employer or healthcare provider is engaging in pharmaceutical fraud or any type of healthcare fraud, contact the qui tam attorneys at Willoughby Brod immediately to report the fraud.

What is Pharmaceutical Fraud?

Pharmaceutical fraud involves illegal actions that pharmaceutical companies engage in that violate the False Claims Act (FCA) or California False Claims Act (CFCA) and result in false claims to insurers and Medicare/Medicaid.

jonathan-perez-409943-copy-300x200During this final week of Medicare open enrollment, you may receive multiple calls each day regarding your Medicare coverage. Many of these calls may be scams, and unless you know exactly what to watch out for, these scams can be difficult to spot. Make sure you follow the guidelines below and report any Medicare fraud you detect to the proper agencies. If you believe your employer or healthcare provider is the one committing the fraud, contact the qui tam attorneys at Willoughby Brod to learn how you can report the fraud and receive an award for your tip.

Four Tips for Avoiding Medicare Scams

  1. Do not give out your Medicare number to anyone other than your doctor or someone who should have it.

james-williams-502481-unsplash-copy-300x225There is no such thing as “good” fraud, but on the hierarchy of Medicare fraud from bad to worst, hospice fraud is arguably one of the most despicable types. Medicare Part A covers hospice care for patients who are “terminally ill,” or have a life expectancy of six months or less. If you believe you have witnessed hospice fraud, make it your duty to report the fraud and honor an individual’s last moments in this world. The whistleblower attorneys at Willoughby Brod are experienced at helping whistleblowers bring their claims forward and protecting them in the process. Contact us today for a free consultation and to learn how we can help.

What Does Medicare Provide by Way of Hospice Care?

As mentioned above, Medicare Part A covers hospice care for patients who are deemed by a medical professional to be terminally ill, which is defined as having a life expectancy of six months or less. Medicare covers only hospice care for terminally ill patients and not any curative treatments, although hospice patients can continue to receive curative care coverage for conditions unrelated to the cause of their terminal illness.

hans-reniers-746177-unsplash-copy-300x200One common category of healthcare fraud schemes in the medical laboratory industry revolves around medically unnecessary testing. There are many different ways in which the medical laboratory industry fraudulently commits medically unnecessary testing, which are highlighted below. If you believe you have witnessed healthcare fraud involving medically unnecessary testing, contact the healthcare fraud attorneys at Willoughby Brod to learn more about what you should do next.

What is Medically Unnecessary Testing?

Medically unnecessary testing occurs when clinical laboratories order tests that are excessive, unnecessary, or inappropriate for a patient’s treatment. Not only can this be extremely costly, it can also be dangerous to a patient’s life.

samuel-zeller-360588-copy-200x300Though similar in purpose, the Anti-Kickback Statute (AKS) and Stark Law have many differences that are often overlooked or ignored by the general public. If you believe you have witnessed a form of healthcare fraud but are unsure whether the fraudulent act was a violation of the AKS or Stark Law, contact one of the experienced AKS and Stark Law attorneys at Willoughby Brod today for your free case review.

What is the Anti-Kickback Statute?

The AKS provides that physicians and hospitals are not permitted to refer patients to other healthcare providers in exchange for something of value, whether in cash or another form. The purpose of this statute is to ensure that referrals are genuine and based on merit rather than based on familial or professional networks.

ken-treloar-385255-copy-300x200Even though the Anti-Kickback Statute is a federal criminal statute that results in serious penalties when violated, it is also one that physicians and healthcare professionals violate on a regular basis. If you believe you were referred to a physician or other healthcare provider as part of a monetary or other valuable exchange, you may have witnessed an Anti-Kickback Law violation. However, there are certain “safe harbors” that protect physician payment plans that would otherwise constitute a violation under the Anti-Kickback Statute. If you are unsure whether your physician’s payment plan falls into one of the safe harbors, contact the attorneys at Willoughby Brod to get your questions answered.

What is the Anti-Kickback Law?

The Anti-Kickback Statute says that physicians and hospitals are not permitted to refer patients to other healthcare providers in exchange for something of value, whether that is cash or something else. The purpose of this statute is to ensure that referrals are genuine and based on merit rather than based on familial or professional networks.

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.