Healthcare Fraud & Whistleblower Actions

Liability under the federal False Claims Act  (“FCA”) occurs where a defendant, either a person or entity,: (1) knowingly presents (or causes to be presented) a false or fraudulent claim for payment; (2) knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim; (3) conspires with others to commit a violation of the FCA; (4) knowingly makes, uses, or causes to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay money or transmit property to the Federal Government.

Who can be a defendant?
Congress intended for the False Claims Act to be read broadly, so the Government could reach all fraud schemes that potentially impact the public purse. In turn, the courts have placed few limits on who falls under the ambit of the False Claims Act, allowing the government to effectively reach all who seek to illegally obtain or keep government funds. The following list identifies some of the common fraud schemes utilized by providers and companies in the healthcare industry.

Pharmaceutical Manufacturer Fraud

• Reporting inflated pharmaceutical prices to Medicare
• Overstating the efficacy to drive off-label sales
• Paying kickbacks to providers
• Knowingly violating FDA specifications for manufacturing

Medical Device Manufacturer Fraud

• Using post-market studies and device registries as vehicles to pay illegal kickbacks
• Marketing medical devices even though the use has not been approved by the FDA
• Manufacturing unapproved medical devices
• Knowingly violating FDA specifications for manufacturing

Biotechnology Manufacturer Fraud

• Providing unlawful kickback payments to surgeons
• Reporting inflated pharmaceutical prices to Medicare
• Overstating the efficacy to drive off-label sales
• Knowingly violating FDA specifications for manufacturing

Medicare Advantage Company Fraud

• Signing letters of agreement with health care providers for service or product discounts and then failing to give Government Health Care Programs the benefit of the negotiated discounts
• Misleading customers about the scope of the Medicare Part C coverage plans
• Deliberately avoiding insuring late-term pregnant women and other potential insureds with a high health-risk status

Medicaid Managed Care Plan Fraud

• Failing to process or pay providers’ health claims in a timely fashion
• Failing to apply a market price adjustment

Copayment Patient Assistance Charity Fraud

• Acting as an illegal conduit to funnel funds from pharmaceutical companies to Government Health Care Program beneficiaries
• For-profit ventures improperly disguised as bona fidecharitable organizations
• Offering inducements or kickbacks to patients and providers to keep patients on certain drugs

Hospital Fraud

• Misclassifying patients as inpatients when they were more appropriately classified as outpatients
• Improperly structuring physician recruitment agreements
• Ordering medically unnecessary overnight admissions

Academic Medical Center Fraud

• Submitting false grant progress reports
• Withholding critical information in applying for government grants
• Improperly billing government agencies while receiving a non-governmental research grant for the same procedure

Hospice Provider Fraud

• Providing hospice care to Medicare beneficiaries who were not eligible for hospice benefits under the Medicare regulations
• Providing hospice care without obtaining the required written certifications of terminal illness
• Misrepresenting the purpose of Medicare’s coverage of hospice services to patients and their families in order to continue to keep them admitted for hospice care

Home Healthcare Provider Fraud

• Including Medicare-covered visits and non-covered visits in calculations of the average cost of home health care visits
• Billing for fees which result in profit when there is a controlling relationship

Skilled Nursing Home Facility Fraud

• Overcharging Medicare for reimbursement of car mileage
• Billing Medicare for medically unnecessary supplies
• Submitting claims for partial hospitalization of patients who suffer from dementia and other symptoms of Alzheimer’s disease, even though such patients do not benefit from that type of treatment

Long-Term Acute Care Provider Fraud

• Submitting claims for services not provided
• Paying illegal kickbacks in exchange for Medicare and Medicaid referrals

Inpatient Rehabilitation Facility Fraud

• Billing Medicare for unnecessary treatments
• Admitting patients whose medical conditions do not warrant inpatient rehabilitation or who will not benefit from the rehabilitation on account of their conditions

Independent Diagnostic Testing Facility Fraud

• Paying kickbacks to providers to induce them to refer Medicare business
• Ordering improper drug screens
• Falsifying drug screen tests

Clinical Laboratory Fraud

• Performing medically unnecessary blood tests
• Improperly charging tests
• Unbundling a single series of blood tests into separate tests to receive higher reimbursements

Pathology Laboratory Fraud

• Billing the Government for unnecessary analyses
• Charging the Government higher prices than those charged for private patients

DME Supplier Fraud

• Repeatedly filing claims for equipment that is never actually provided
• Failing to pass through discounts to the Medicare program
• Using or causing falsified documents to support claims of medical necessity

Outpatient Rehabilitation Facility Fraud

• Double billing Medicare for costs associated with the delivery of physical, occupational and speech therapy services

Occupational Therapy Facility Fraud

• Upcoding and double billing Medicare for costs associated with the delivery of occupational therapy services

Psychiatric Treatment Facility Fraud

• Providing substandard psychiatric counseling and treatment in violation of Medicaid requirements
• Falsifying the attendance rosters of outpatient psychiatric group meetings
• Billing the Government for a higher level of service than actually provided

Medicare Administrative Contractor Fraud

• Falsifying audit activity dates
• Submitting false information regarding the accuracy and timeliness of processed claims
• Knowingly failing to recover money owed to the Government

University Research Facility Fraud

• Submitting  false grant progress reports
• Billing government healthcare programs while receiving a research grant for the same procedure

Our attorneys are experienced litigators and former prosecutors who have obtained multi-million dollar recoveries under the False Claims Act and have successfully represented those in whistleblower protection and other whistleblower-related actions against their employers. Contact us today to schedule a consultation about your case.