Articles Tagged with attorney for health care whistleblowers

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.

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.

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.

hush-naidoo-382152-copy-300x200Alere, 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

clark-young-143622-unsplash-copy-300x200In 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.

freestocks-org-126848-1-copy-300x200In April 2018, the U.S. Attorney’s Office for the Southern District of California announced that two physicians pled guilty to participating in a health care fraud scheme against TRICARE, the health care program for U.S. service members and their families. Carl Lindblad, 53, and Susan Vergot, 31, were charged with fraudulently obtaining more than $65 million by unnecessarily prescribing expensive compound medications for patients they did not see in person.

Fraud Related to Compound Medications

Compound medications are specialty medications created when a patient has a specific need that cannot be addressed with a regularly existing prescription. Compound medications are not approved by the U.S. Food and Drug Administration, yet they typically involve a variation on a previously FDA-approved drug. For instance, a patient may need a specific drug yet be allergic to a dye or one of its ingredients. A patient may require a dosage that a certain drug is not manufactured in. Compound medications are expensive because they must be mixed by a pharmacist in regard to the patient’s needs.

andres-de-armas-103880-copy-300x200In early April, two executives for a business offering alcohol and drug abuse treatment services were arrested for healthcare fraud. Mesbel Mohamoud, 45, and Erlinda Abella, 63, both of Inglewood, are accused of submitting bills to Medi-Cal for services that were either not provided or were not eligible for reimbursement. Authorities allege Mohamoud and Abelle fraudulently sought more than $2 million in reimbursements.

If you have any information regarding a healthcare business fraudulently billing a federal or state medical program, contact a San Francisco health care fraud lawyer at Brod Law Firm right away.

Further Details of Alleged Healthcare Fraud

hush-naidoo-382152-copy-300x200The federal government’s False Claims Act (FCA) case against United Health Group (UHG) continues after major developments. In the case of U.S. ex rel. Benjamin Poehling v. UnitedHealth Group, Inc., The U.S. District Court in the Central District of California dismissed half of the claims brought through the initial qui tam suit and the government’s revised complaint. A short time later, the Department of Justice (DOJ) decided to not continue with a part of the suit and to focus on the remaining claims.

The District Court’s Decision

In February 2018, the district court analyzed the government’s amended complaint based on the FCA’s materiality requirement. Based on the Supreme Court’s decision in Universal Health Servs. Inc. v. United States ex rel. Escobar, the government must plead that their allegations are material to the government’s payment decision. They must demonstrate that, if the facts are true, the unlawful conduct influenced how much the government paid the other party.

vladimir-kudinov-71455-copy-300x241Physicians Vilasini Ganesh, 47, and Gregory Belcher, 56, were convicted in December of committing health care fraud and making false statements to health care programs. A federal jury found Ganesh guilty of five counts of health care fraud and five counts of making false statements relating to fraudulently submitted claims. Belcher was found guilty of one count of making a false statement regarding a health care benefit program. Both were acquitted of conspiracy and money laundering charges.

Health Care Fraud and False Statements

Evidence presented at trial showed Ganesh, who was the head of Campbell Medical Group, submitted false and fraudulent claims to several health benefit programs for services. She submitted claims for days when patients had not seen a health care provider and claims that patients had been seen by another physician who was no longer with her practice.