Healthcare Fraud

March 23, 2016

Penalties in California Health Care Fraud

Health Care Fraud is commonly known by other names such as health insurance fraud, medical billing fraud, health insurance fraud and Medi-Cal Fraud. The complicated and confusing bureaucracy associated with the payment process has lead to authorities accusing innocent providers and beneficiaries of health care fraud. In many instances these are just the result of honest mistakes.

Common Examples of Fraudulent Conduct

Health Care Fraud is an intentional attempt by some providers, and in some cases beneficiaries, to receive unauthorized payments or benefits from the program. This fraud can take many forms, but the most common instances involve knowingly billing for services not performed, billing for more expensive services than the ones the patient actually received (known as “upcoding”), providers billing for the care of more beneficiaries than they can actually serve, and submitting a second duplicate claim for services already paid for.

March 7, 2016

Massive Settlement in Series of Cases Started by a Whistleblower Concerned About Health Care Fraud

by Gregory J. Brod

As concerned citizens and as a health care fraud law firm, our team continues to be pleased with the terrific successes whistleblowers are having using the False Claims Act, Anti-Kickback Statute and related federal and state statutes to fight fraud in the medical field. A major settlement announced this month involving improper health care kickbacks shows just how successful these cases can be and how several different laws can work in concert to provide justice. Yet, we know that for every victory, there are countless other companies and individuals committing health care fraud and stealing from the American people. We cover these issues extensively to let those who witness these crimes know they are not alone. We are here to help them follow the right path and truly do a service to their country.

DOJ Announces Largest Total Settlement Involving Illegal Kickbacks in Medical Device Field

The Department of Justice (“DOJ”) announced this month that the largest distributor of endoscopes and related equipment has agreed to pay $623.2 million to settle several lawsuits involving allegations it paid inappropriate kickbacks to doctors and hospitals. Defendant Olympus Corporation of the Americas (“Olympus”) has admitted to the allegations in a criminal complaint filed in a New Jersey federal court based on the Anti-Kickback Statute (“AKS”) and the related suits rest on similar allegations. This settlement involves the largest total amount paid to date by a medical device company for violations involving the AKS. Olympus has entered into a deferred prosecution agreement that allows it to avoid criminal conviction if it complies with the reforms contained in the agreement.

February 29, 2016

Government Fraud Attorney on the Importance of Protecting Whistleblowers in False Claims Act Cases

by Gregory J. Brod

You’ve witnessed something amiss in your workplace. Whether it is a medical practice routinely upcoding Medicare claims to charge for more expensive procedures than were actually performed, a government contractor cheating the government by providing goods that are inferior to those promised, or another form of overcharging the government, you suspect your employer is committing fraud on the government. You know the right thing to do is report it, perhaps asking questions internally and then turning to outside help if that doesn’t resolve the issue. Still, you are scared. At The Brod Law Firm, our whistleblower’s law firm understands your concerns and we want to assure you that the law does as well. In addition to providing a substantial reward to those who bring fraud cases under the False Claims Act on the government’s behalf, the law includes anti-retaliation provisions and substantial government fraud whistleblower protections. We are committed to ensuring whistleblowers are protected from retaliation because we believe whistleblowers are providing a critical service to the American people.

The False Claims Act: The Role of Private Whistleblowers and the Rules Protecting Them

As long-time readers of this blog know, the False Claims Act (“FCA”) is one of the most powerful tools for fighting fraud on the U.S. government. Chapter 31 Section 3729 of the United States Code makes it illegal for an entity/individual to knowingly make a false claim for payment from the federal government or its agencies, including using a falsified record to support an inappropriate claim. A key part of the subsequent section, 31 U.S.C. §3730, allows private individuals (“relators”) to bring FCA claims on the government’s behalf. The government then has the option of joining the suit (“intervening”) or having the whistleblower proceed with the prosecution. If the relator’s information and efforts lead to the government recovering money, the relator is entitled to between 15 and 30 percent of the recovered funds.

February 22, 2016

Implied Certification, Take Two: A Look at the California False Claims Act and Fraud on State Governments

by Gregory J. Brod

Last week, we wrote about the upcoming Supreme Court case that will decide if the implied certification theory is a valid interpretation of the Federal False Claims Act (“FCA”). It is a decision that could substantially empower government fraud whistleblowers. However, it is worth remembering that the federal false claims act is only relevant to cases involving alleged fraud on the federal government, including Medicare fraud. State false claims acts, which in many cases are relatively similar to their federal counterpart, are a key tool for fighting fraud on the state government including state-level government contract fraud and Medicaid fraud (a joint state/federal program). Our government fraud law firm supports whistleblowers nationwide, including in our home state of California. The case law specifically supports implied certification under the California False Claims Act (“CFCA”) and we believe other states may accept the theory as well.

Courts Hold Implied Certification Theory Valid Under California False Claims Act

lawbooks In San Francisco Unified School Dist. ex rel. Contreras v. Laidlaw Transit Inc., 182 Cal. App. 4th 438 (Cal. App. 1st Dist. 2010) and again in a 2014 decision, the Court of Appeals for the State of California considered a suit brought by a group of whistleblowers on behalf of the San Francisco Unified School District (“District”) under the CFCA. The Plaintiffs alleged that the Defendant submitted payment claims to the District despite knowing it was in breach of assorted contract terms relating to student transportation services. These violations allegedly rendered the Defendant’s buses unsafe and unhealthy. The Plaintiffs also alleged that the Defendants knowingly falsified records and/or statements.

February 15, 2016

The Implied Certification Debate: A Major Issue in False Claims Act Litigation Pending Before the U.S. Supreme Court

by Gregory J. Brod

Last year, our health care fraud whistleblowers’ law firm reported on an important issue in the False Claims Act arena: implied certification. The implied certification theory has the potential to be a powerful tool in the fight against fraud and, when we last discussed the topic, the Fourth Circuit Court of Appeals had ruled in favor of the theory. However, there has been disagreement on the issue among the federal appellate courts and the issue is headed to the Supreme Court. We continue to believe in the implied certification theory and we are closely following the issue as it makes its way to the highest court in the land.

The Escobar Case

As Modern Healthcare recently reported, the implied certification theory is heading to the Supreme Court via the case of Universal Health Services v. United States ex rel Escobar. The case involves a claim filed by the parents of a teenager who died while under the care of a mental health clinic. The plaintiffs allege that the clinic’s staff was not properly supervised and that the clinic lacked required board-certified or board-eligible supervisory personnel. As the First Circuit wrote, “The crux of their complaint is that [Defendants’] alleged noncompliance with sundry supervision and licensure requirements rendered its reimbursement claims submitted to the state Medicaid agency actionably false under both the federal and Massachusetts False Claims Acts.”

February 8, 2016

Protecting Whistleblowers Who Join the Fight Against Health Care Fraud

by Gregory J. Brod

By its nature, fraud is a crime of secrets. The depth and breadth of these secrets are part of the reasons why whistleblowers are such an essential part of the fight against health care fraud. The law recognizes this and both rewards and protects health care fraud whistleblowers for their role in helping return wrongfully diverted government health care funds to already-strained program budgets like Medicare and Medicaid. As a whistleblowers’ law firm, The Brod Law Firm is proud to work with the men and women who speak up when others might remain silent.

Whistleblower Files Retaliation Lawsuit Against Former Employer

One whistleblower in Oregon is currently pursuing a lawsuit against his former employer claiming illegal retaliation based on his role in reporting potentially fraudulent Medicare claims. According to The Oregonian, Dr. Robert Dannenhoffer filed a federal whistleblower claim late last week against Architrave Health LLC, a health care organization in southern Oregon. Dr. Dannenhoffer claims that a subsidiary company, Umpqua Medical Group, set up an improper compensation structure that rewarded doctors for prescribing certain medications and procedures for Medicare patients. He says the pay structure led to inflated Medicare payments in violation of both the False Claims Act, a general law dealing with fraudulent claims for government funds, and the Stark Act, a law specifically limiting the ability of medical providers from profiting on referrals.

January 25, 2016

Nursing Home Billing Fraud Update: Rehabilitative Therapy Contractor Settles Case, Whistleblower and Federal Government Alleged Company Put Profit Over Patient Care

by Gregory J. Brod

It is a simple concept — health care should be dictated by the patient’s needs rather than the provider’s fiscal interest. While most providers adhere to this core principle, far too many do not, especially in the long-term and nursing home care arenas. Nursing home billing fraud, including rehabilitative therapy fraud, is a violation of patient trust and medical ethics as well as a serious financial wrong that diverts money away from genuine medical needs. As a Medicare billing fraud law firm, we monitor this area of law closely and we fight back by working with honest whistleblowers who come forward to report these wrongs.

DOJ Press Release Details Alleged Frauds in Recently Settled False Claims Act Case

A Department of Justice (“DOJ”) press release issued on January 12 demonstrates the DOJ’s continuing commitment to supporting whistleblower-led Medicare billing fraud claims in 2016. Kindred Healthcare Inc. and its subsidiaries RehabCare Group Inc. and RehabCare Group East Inc. (collectively “RehabCare”) have agreed to healthmoney pay $125 million to resolve a False Claims Act (“FCA”) lawsuit. RehabCare is the nation’s largest provider of rehabilitative therapy, contracting with over 1,000 nursing homes nationwide to provide patient care. Four nursing homes will also pay a total of $8.225 million in connection with the settlement. While the settlement resolves the claims, it is not an admission of wrongdoing and all claims detailed below remain allegations.

January 11, 2016

The False Claims Act and the Health Care Fraud Fight in 2016

by Gregory J. Brod

The False Claims Act (“FCA” or “the Act”) is one of the most important tools we have in the fight against health care fraud and other frauds on the federal government. When an organization or individual knowingly takes more money from the government than the law allows or otherwise submits a false claim to the government, the FCA allows the government to recover triple damages plus an appropriate penalty. Examples of false claims include overcharging Medicare for medical treatment and supplying the military with goods that don’t meet contractual requirements. The Act has a special qui tam provision that allows individuals to act as whistleblowers and bring claims on the government’s behalf, a critical tool because fraud is difficult to uncover without help. Although the law provides whistleblowers with a substantial reward for their time and effort if their case leads to a recovery via either a settlement or judgment, most whistleblowers are motivated by a desire to do the right thing and our government fraud law firm is proud to help them.

Recently, we’ve looked back on the success of the FCA in 2015. Today, we look ahead at what 2016 may hold in the health care fraud arena, the sector responsible for the largest share of FCA recoveries in 2015. Becker’s Hospital Review, a leading journal for the health care industry, identifies the following five trends expected to fuel FCA recoveries in the coming year[1]:

Extrapolation – Extrapolation involves examining a sample of payment claims and applying the information learned to all similar claims filed by the same organization. This is a useful shortcut in cases alleging large-scale fraud. Defendants have contested (and will likely to continue to fight) the use of extrapolation claiming it unfairly lowers the government’s burden of proof, but courts have largely ruled in the government’s favor.

January 4, 2016

A Closer Look: Health Care Fraud Recoveries in 2015

by Gregory J. Brod

In Fiscal Year 2015, the government, often with the assistance of private whistleblowers, recovered more than $3.5 billion using the False Claims Act to target companies and individuals who attempted to commit fraud and steal money from federal government programs. We took a broad look at these recoveries a couple of weeks back, today we take a narrower focus: health care fraud. We believe that looking at these cases can help people understand what sort of actions violate the FCA and encourage them to contact our whistleblowers’ law firm. As the 2015 numbers show, the FCA works and individuals can play a major role in the fight against fraud targeting Medicare, Medicaid, and other vital government health care programs.

$1.9 Billion Recovered in Health Care Fraud False Claims Act Cases in 2015

According to the Department of Justice’s press release announcing the successes under the FCA in FY2015, $1.9 billion of the $3.5 billion recovered on behalf of the federal government last year came from the health care industry. This makes the total health care fraud dollars recovered via the FCA since January 2009 nearly $16.5 billion. Importantly, these numbers are limited to federal dollars returned to federal programs. Quite often, health care fraud prosecutions include additional charges involving state programs and can include recoveries on behalf of these programs as well, especially when cases involve Medicaid which is a joint federal/state venture.

December 28, 2015

Looking at the State Side of Government Fraud Claims: Washington Examines its Medicaid Fraud False Claims Act

by Gregory J. Brod

Last week, we looked at the recoveries made on behalf of the federal government using the False Claims Act (“FCA”) in 2015. While informative, those numbers don’t tell the whole story. Many states have their own versions of the FCA. These statutes are particularly important in the Medicaid fraud arena since Medicaid is a state and federal partnership so fraud typically involves both federal and state funds. Today, our government fraud law firm looks at one such statute, Washington’s Medicaid Fraud False Claims Act (“WFCA”). Each state’s laws are unique, but this review can help readers understand the importance of state claims in this arena.

Washington’s Legislative Auditor Reviews the State False Claims Act, Recommends Reauthorization

In 2015, with the WFCA set to expire on June 30, 2016, the healthcash state’s Legislative Auditor undertook to study the statute, its results, and recommend or counsel against reauthorization. As the resulting report (Proposed Final Report issued 12/16/15) explains, government can investigate possible Medicaid fraud via federal (civil and/or criminal) investigations, state criminal investigations, and state civil investigations. Absent reauthorization, Washington would lose the authority for the final category. Additionally, if the federal government is investigating a case that also involved fraud on Washington state, the state can only participate in the case and any recovery if it has a state FCA that (like the WFCA) meets certain standards set forth in the federal law.