Articles Tagged with health care fraud whistleblowers’ law firm

hush-naidoo-382152-copy-300x200There are many different types of whistleblower claims that involve physicians and other medical providers defrauding the government. Some of the most common involve Stark Law violations. Stark Law was enacted over two decades ago and was meant to ensure that patients receive the best care possible, and that physicians always work in their best interests. Today, Stark Law has become complicated, and it seems the laws are changing all the time. If you work in the medical industry, below are five things you should know about Stark Law to ensure your employer operates honestly and within the confines of the law.

Stark Law Bans Self-Referrals

When it was enacted in 1989, the concept behind Stark Law was relatively simple. The law was intended to ban self-referrals made by doctors for certain services when a patient was covered through Medicare or another government program. The law was named after Representative Pete Stark, the Democrat from California that sponsored the bill.

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.

Few dpharmacyecisions are as important as those regarding our health and the health of our loved ones.  Decisions about medications, like many other health-related issues, involves a weighing of risks and benefits.  With increased direct-to-consumer advertising and pressure on doctors from corporations, this calculus can be extremely hard.  Americans must be able to trust that information released by pharmaceutical companies is accurate.  In some cases, pharmaceutical company fraud can amount to a violation of the False Claims Act which means ordinary Americans have the power to fight back with the help of our health care fraud law firm.

Settlement in Suit Alleging Pharmaceutical Companies Misled Doctors and Others About Cancer Drug

On June 6, the Department of Justice (“DOJ”) announced that Genentech Inc. and OSI Pharmaceuticals LLC will collectively pay $67 million to settle allegations the companies made misleading statements about the drug Tarceva.  A lawsuit filed under the False Claims Act alleged that, from 2006 through 2011, the companies made misleading representations to medical care providers about Tarceva’s ability to treat certain non-small cell lung cancers.  In actuality, according to the DOJ, there was little evidence that Tarceva could treat these cancers unless a patient had never smoked or had a particular mutation in their epidermal growth factor receptor.

The False Claims Act is a powerful weapon and, as we’ve talked about on this page numerous times, a large part of that power comes from the fact that ordinary citizens can use it to fight many forms of fraud on the United States government.  After the initial filing of a whistleblower fraud claim, the government will eventually decide whether or not to intervene in the case.  This is an important part of the process and our whistleblowers’ law firm knows that intervention in False Claims Act cases, such as recently occurred in a health care fraud suit, is often a positive sign.  However, it is important to know that claims can be and are successful even absent government intervention.

The FCA and Intervention Generally

lawbooksThe False Claims Act (“FCA” or “the Act”) is a Civil War Era statute that was reenergized by a series of amendments in the 1980s.  In short, a company or individual violates the Act when it defrauds the government, typically by overcharging the government or a government agency.  Under 31 U.S.C. §3730(b), private citizens are given the power to bring FCA claims on the government’s behalf.  These whistleblowers, also known as relators, are crucial since fraud by its nature is secretive and the government could not effectively fight fraud without the assistance of individuals who witness fraudulent acts.  After the suit is filed, the government investigates the claim and then the Department of Justice (“DOJ”) decides whether or not it wants to take over the case.  The decision to do so is known in legal circles as intervention.

Cancer.  Rarely can one word strike so much fear.  We have come so far in both cancer prevention and cancer treatment; yet we also have so much farther to go before we can truly say we’ve triumphed over this massive beast.  One major challenge is the cost of treating cancer.  While much of that cost is due to the challenges of medical research, some companies are deliberately over-charging cancer patients and their insurance providers by billing for expensive and unnecessary services.  The battle against cancer treatment fraud is yet another example of a front in which the False Claims Act can be a tool for justice and even a tool for health.  As a health care fraud law firm, we partner with whistleblowers to fight these wrongs and ensure health care funds are available for true medical needs.

Company Pays Nearly $34.7 Million to Settle Allegations of Overbilling for Cancer Treatment

Earlier this Spring, the Department of Justice (“DOJ”) announced that 21st Century Oncology agreed to pay nearly $34.7 million to settle a False Claims Act lawsuit alleging they performed and billed federal health care agencies (e.g., healthcashMedicare, Tricare, Medicaid) for procedures that were not medically necessary.  The underlying suit involved a procedure called the Gamma function which measures the exit dose radiating from an individual after radiation treatments.  The government alleged that the company performed and billed for this procedure when it was not needed for any medically appropriate purpose.  Additionally, the suit alleged that 21st Century billed for Gamma function treatments in cases where no physician reviewed the results in a timely manner and in cases where technical equipment failures meant no results could be obtained.  The suit was originally brought by a former physicist with a Florida oncology company who filed the claims under the whistleblower or qui tam provisions of the False Claims Act and who will receive over $7 million for his role in the case.

We talk a lot courthouseabout the False Claims Act (“FCA” or “the Act”)) on this blog.  We do that because it is a powerful tool that allows ordinary Americans to take a stand and fight fraud.  The frauds it fights are frauds perpetrated against the government and government programs, frauds that are ultimately crimes against the American people.  Our posts often look at specific cases involving alleged violations of the FCA, but from time to time our whistleblowers’ law firm likes to take a step back and look at the FCA more generally to help our readers understand exactly what kind of wrongs the FCA tackles.

“A False or Fraudulent Claim”

The FCA is actually several sections of the United States Code, with 31 U.S.C. §3729 containing the basic description of what actions violate the Act.  Although it is only one of a number of subsections that describe these actions, §3729(1)(a) explains the basic wrong the Act tackles “a false or fraudulent claim for payment or approval.”  Essentially, this means that a person or entity is liable under the Act if they ask the government to pay an obligation that is not actually due or ask for more money than they are actually due.

We can tell you that the False Claims Act is a powerful tool for fighting the growing epidemic of health care fraud in the United States.  We prefer, however, to show you by citing some of the biggest verdicts and settlements in the field.  This week, we highlight a settlement involving allegations of Medicaid fraud in the pharmaceutical industry.  As a Medicare and Medicaid fraud whistleblowers’ law firm, we help honest witnesses bring lawsuits in cases like this one to fight back against pharmaceutical company fraud and other cases of fraud against government health care programs.

Drug Company to Pay $784.6 Million to Settle Claims It Failed to Report Accurate Pricing Data and Underpaid Medicaid Drug Rebates

On April 27, the Department of Justice (“DOJ”) issued a press release announcing that Wyeth and Pfizer (Pfizer acquired Wyeth after the alleged conduct ended; defendants referred to collectively as “Wyeth”) have agreed to pay $784.6 million to settle a False Claims Act suit alleging Wyeth committed Medicaid fraud by reporting false prices on pill$two of its medications.  The complaint alleged that Wyeth gave thousands of hospitals deep discounts on two protein pump inhibitor drugs but failed to report these lower prices to the government.  Allegedly, Wyeth used a bundled sales agreement to induce hospitals to purchase two of its drugs and place them on hospital formularies.  The government believes Wyeth sought to control the hospital market in part because patients often stay on the drugs for a long time after discharge and payers, including Medicaid, would then end up paying nearly full price for the medications.

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 doctor2care 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.

healthcashThe 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]:

  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.

The relationship between health care and money is the crux of some of the biggest policy debates of our time.  Still, while much is debated, there are also many principles that most Americans agree should hold true.  One such maxim – Medical decisions should be based on the best interests of patients, not providers own financial well-being.  This precept is reflected in several laws including the Anti-Kickback Statute and the Stark Act and enforcing these rules is one of the goals of our work as a whistleblowers’ law firm for health care fraud issues.

$115 Million Settlement Resolves Case Alleging Health System’s Bonuses Violated Law

Just last week, the Justice Department (“DOJ”) announced a major settlement in a health care fraud case involving allegations of improper financial relationships between health care providers and their referral sources.  The lawsuit claimed that Adventist Health Systems, a healthcare organization with facilities in 10 states, billed for the services of employed providers who were paid bonuses that, contrary to law, were based on a formula that considered the value of the referrals to the hospital system.  More specifically, the suit alleged that doctors received monetary bonuses tied to the number of tests and procedures they ordered.  Adventist agreed to pay $115 million to settle these and other fraud allegations, but did not admit to any wrongdoing.