Medicare fraud law firm

August 15, 2016

Lessons from a False Claims Act Ruling on Medicare Pricing and the “Usual and Customary” Price

We pride ourselves on our work helping whistleblowers bring claims pursuant to the False Claims Act. As a False Claims Act law firm, we have specialized knowledge of this complex piece of legislation that empowers individuals to bring fraud claims on behalf of the government. A ruling from a federal district court released in late Spring in a case alleging Medicare fraud looks at one of the many important details that come up in these cases. More specifically, the case looks at what constitutes a “usual and customary” price for purposes of determining whether a provider is complying with the law and offering Medicare beneficiaries an appropriate price on prescription drugs. In doing so, the court highlights one important requirement that is often subverted by perpetrators of fraud and also provides a reminder of how complex False Claims Act cases can be.

Background on the Garbe Case

On May 27, 2006, the Seventh Circuit Court of Appeals released an important ruling in United States ex rel. Garbe v. Kmart Corporation, a False Claims Act case brought by James Garbe on behalf of the United States against Kmart. According to the complaint, Garbe, a pharmacist at Kmart, noticed that another pharmacy charged his Medicare Part D insurer substantially less that Kmart typically charged insurers for the same prescription. He investigated and found that Kmart routinely charged customers paying out of pocket less than it charged those paying with insurance (public or private). He also found that most cash customers took part in Kmart’s “discount programs” and that this discount price was not included when Kmart calculated its “usual and customary” prices on generic medications for purposes of Medicare reimbursement.

August 8, 2016

Charges in an Allegedly Massive Scheme Highlight the Danger of Medicare Fraud

by Gregory J. Brod

Is Medicare fraud really that big of a problem? After all, doesn’t fraud exist in almost every sector of the economy? Why focus so much energy on one issue? As recently filed charges in one case show, Medicare fraud is an enormous problem that costs our government billions of dollars every year. Stealing from the government is, in essence, stealing from every single taxpayer. Medicare fraud diverts money from those who truly need and deserve health care services and puts the money in the pockets of wrongdoers. At the same time, there is also very specific, personal harm to patients whose providers are involved in fraudulent schemes, patients whose health is put in jeopardy because a provider puts profit over care.

DOJ Announces Allegations of Fraudulent Medicare Billing in Excess of $1 Billion

Late last month, Assistant Attorney General Leslie R. Caldwell publicly announced the unsealing of charges in what she called “the largest single criminal health care fraud case ever brought against individuals by the Department of Justice.” The case involves allegations of fraudulent billing that total over $1 billion. The allegations are focused on a group in South Florida, a region particularly hard hit by Medicare fraud.

November 9, 2015

Cheat the System, Pay the Price: Pursuing Those Who Knowingly Violate Medicare Rules

by Gregory J. Brod

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 50^th 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).”