Articles Tagged with attorney for Medicare fraud

daniel-frank-201417-copy-300x200CareCore 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.

There are few topics that will get people talking (and, inevitably, complaining) like health insurance.  The truth of the matter is that, in order to function efficiently and provide the best possible care to the largest possible audience, health insurance companies must have rules and guidelines.  Perhaps the context where this principle is most important is when the insurer is Medicare.  According to a government memo published in July marking the program’s 50th year, Medicare currently covers 55 million beneficiaries, an increase of 3 million beneficiaries from just three years ago.  While coverage rules are sometimes unpopular, they exist for a reason and organizations that repeatedly bill and collect money in violation of Medicare coverage rules put the system and all who rely on it in jeopardy.  The government cannot examine every claim in depth making health care fraud whistleblowers critical to protecting the system, one of the many reasons we are proud to serve as a Medicare fraud whistleblower’s law firm.

Settlement Resolves Allegations 450+ Hospitals Violated Medicare Guidelines for Cardiac Devices

On October 30, the Department of Justice (“DOJ”) announced that it had reached 70 related settlements totaling over $250 million dollars resolving allegations that 457 hospitals (listed in a separate document) in 43 states violated Medicare rules related to implantable cardiac devices.  Most of the hospitals were named as defendants in a lawsuit filed under the False Claims Act (“FCA”) which contains a special qui tam provision allowing private whistleblowers to file claims on the government’s behalf.  In this case, the original suit was filed by a cardiac nurse and a health care reimbursement consultant.  Pursuant to the FCA, the whistleblowers received over $38 million from the settlement.  While some might suggest that amount seems excessive, as the legal news website Lawyers and Settlements notes, “when the depth and breadth of the alleged healthcare fraud is factored in, it soon becomes clear the contributions of the two lead plaintiffs were integral in what has been described as one of the largest examples of alleged healthcare fraud, in terms of the number of defendants, in the history of the False Claims Act (FCA).”

Who are the victims of Medicare fraud?  As a law firm specializing in health care fraud matters, we understand that question requires a multi-part answer.  At the broadest level, Medicare fraud is theft and the target is a taxpayer-funded government program, meaning every U.S. taxpayer is a victim.  Narrowing the focus a bit, Medicare fraud depletes an already strained budget and thus it jeopardizes the health and well-being of all Medicare beneficiaries.  Medicare fraud also has more specific victims, individuals who are treated as mere pawns by the scammers.  A recent case involving mental health benefit fraud in Texas brings these individual victims to the forefront of our minds.

Medicare and Mental Health

Medicare recognizes that true health involves both physical and mental well-being.  In order to understand the Texas case, it is helpful to understand a bit about Medicare’s mental health coverage.  Medicare Part B includes outpatient mental health services holdinghandfor all program beneficiaries.  This coverage includes an annual depression screening and necessary outpatient mental health treatment such psychotherapy and medication management.   If a beneficiary requires inpatient mental health treatment, coverage is provided via Medicare Part A, the hospital insurance arm of the program.