Government Healthcare Fraud

Government Healthcare Fraud

Healthcare fraud against the government occurs when an individual or corporation files a claim to obtain reimbursement from government healthcare programs for products or services based on false claims. The two government health care programs most vulnerable to fraud and abuse are Medicare, which serves people who are 65 or older, and Medicaid, which covers individuals with limited resources.

Tricare, a government program that provides military personnel with civilian healthcare benefits, is also susceptible to false claims and fraudulent activity. Tricare enrollment is open to active service members and their families, National Guard and Reserve members, and retirees. The United States Department of Defense Military Health System administers Tricare, although the government has contracts with several large private insurance corporations to provide claims processing, administrative functions and customer service.

Baum Hedlund Aristei & Goldman Announces that NeuroScience/ Pharmasan Labs Pays $8.5 Million to Settle Whistleblower Laawsuit

Types of Healthcare Fraud Schemes

Healthcare fraud can be found in all parts of the nation’s healthcare system, including medical clinics, hospitals, nursing homes, residential care facilities, and home healthcare companies.

Some of the most common schemes used to defraud government healthcare programs include:

  • Billing for products or services that were never provided.
  • Billing for medically unnecessary services.
  • Billing for excessive services, e.g., daily medical office visits when a few times monthly would be sufficient.
  • Overcharging for the goods and services that were provided. Two of the most common schemes are:
    • Upcoding of services or supplies: Each medical procedure has a corresponding billing code attached to it. A criminal provider might submit a bill using a procedure code that will give them a higher payment instead of the actual code for the service provided, for example, using a code for individual therapy, when group therapy was provided. Upcoding may also apply to supplies – e.g., billing for more expensive items when cheaper ones were provided.
    • Unbundling: This involves submitting separate bills for tests or procedures that were performed at the same time and should have been billed together at a reduced cost.
  • Paying kickbacks in exchange for the referral of patients for health care services.
  • Durable Medical Equipment (DME) fraud: Wheelchairs, catheters, and home oxygen or insulin pumps are examples of the many types of DME. Schemes include upcoding and unbundling (submitting multiple bills for component parts), billing for more expensive items than were actually provided, shipping DME without proper medical authorization, shipping DME that was never ordered, and failing to credit Medicare for returned items.

Healthcare Fraud Whistleblower

Healthcare fraud is prosecutable under the False Claims Act (FCA), which rewards and protects whistleblowers who file whistleblower (qui tam) lawsuits against fraudulent providers.

Some of the following healthcare fraud settlements illustrate the important role that whistleblowers and the FCA play in exposing fraud:

  • North Atlantic Medical Services Inc. (NAMS), a Massachusetts company, agreed to pay $852,378 to resolve allegations that it violated the False Claims Act by submitting claims to Medicare and Medicaid for respiratory services provided by unlicensed personnel. The government investigation was triggered by a whistleblower lawsuit filed under the FCA by two former NAMS employees. They will split a whistleblower award of $153,428
  • DaVita Healthcare Partners, Inc., a company that operates dialysis clinics in 46 states and the District of Columbia, paid $350 million to resolve claims that it violated the False Claims Act by paying kickbacks to physicians for referring patients to its clinics. Such payments have been made illegal to ensure that health care decisions are based only on the medical needs and interests of the patient, not financial gain for the doctor. Here again, the charges were originally brought in a qui tamlawsuit filed by a whistleblower, a senior financial analyst with the company.
  • Dignity Health, one of the largest hospital systems in the nation, agreed to pay $37 million to settle charges that 13 of its hospitals in California, Nevada and Arizona knowingly submitted false claims to Medicare and Tricare by admitting patients who could have been treated on a less costly, outpatient basis. The settlement resolved a lawsuit brought by a whistleblower who was a former Dignity employee under the qui tam provisions of the False Claims Act (FCA). She will receive a whistleblower award of approximately $6.25 million.

Using the False Claims Act to Fight Healthcare Fraud

Individuals who have knowledge of fraudulent practices in the healthcare industry can take action on behalf of the U.S. government by filing a whistleblower lawsuit. The FCA allows a healthcare fraud whistleblower to file what is known as a qui tamlawsuit against an individual or business that is engaged in fraud against the government.

The Department of Justice, which prosecutes FCA actions, is notified of the lawsuit and may at some point decide to intervene in the case. If the action results in a successful enforcement action, the whistleblower may receive 15 percent to 25 percent of the amount recovered.

It is important that anyone seeking to file a qui tam lawsuit receive expert legal assistance. An experienced whistleblower attorney can protect your rights, give you the best chance of a successful outcome and ensure that FCA rules are followed to maximize any award.

If you have knowledge of healthcare fraud and are considering taking action, please contact the Baum Hedlund Aristei & Goldman whistleblower attorneys today for a free case consultation.

Contact Us Today

No Fees Unless We Win
  • Please enter your first name.
  • Please enter your last name.
  • +1
    Please enter your phone number.
    This isn't a valid phone number.
  • Please enter your email address.
    This isn't a valid email address.
  • Please enter your city.
  • Please make a selection.
  • Please make a selection.
  • Please make a selection.
  • Please enter a message.
  • Whistleblower Settlement $18 Million

    $18 million settlement for Boeing government overcharging on aircraft maintenance

  • Whistleblower Settlement $8.5 Million
  • Whistleblower Settlement $8.5 Million
  • Whistleblower Settlement $6.5 Million
  • Whistleblower Settlement $1.2 Million
  • Whistleblower Settlement $1.3 Million
  • Best Law Firms 2022
    Best Law Firms 2022

    A ranking in The U.S. News – Best Lawyers® “Best Law Firms” is widely regarded by both client and legal professionals as a significant honor. It is considered the most reliable, unbiased source of legal referrals anywhere.

  • National Trial Lawyers Top 100
    National Trial Lawyers Top 100

    The National Trial Lawyers Top 100 recognized the law firms of Baum Hedlund Aristei & Goldman, the Miller Firm and Audet & Partners with the 2019 Trial Team of the Year award (in the Mass Torts category) for their work in the groundbreaking case of Dewayne “Lee” Johnson v. Monsanto Company.

  • California Powerhouse
    California Powerhouse

    Law360 recognizes law firms that have a strong regional presence, working on important matters within their home state. “[Baum Hedlund] possesses a David v. Goliath-sized slingshot while seeking justice for everyday citizens it believes were harmed or killed through corporate wrongdoing.”

  • Elite Trial Lawyers
    Elite Trial Lawyers

    NLJ and American Lawyer Media honor law firms and attorneys as Elite Trial Lawyers for their cutting-edge legal work on behalf of plaintiffs in practice areas ranging from mass torts to securities litigation.

  • Listed in Best Lawyers
    Listed in Best Lawyers

    Best Lawyers is the oldest and most respected peer-review publication in the legal profession. A listing in Best Lawyers is widely regarded by both clients and legal professionals as a significant honor, conferred on a lawyer by his or her peers.

  • AV Top Ranked Law Firm
    AV Top Ranked Law Firm

    Less than one-half of one percent of firms across the nation have achieved this ranking. A firm must have a high percentage of lawyers who have achieved the prestigious AV® Preeminent rating by Martindale-Hubbell®.

  • Verdicts Hall of Fame
    Verdicts Hall of Fame

    The National Law Journal inducted Baum Hedlund into the Verdicts Hall of Fame for obtaining the $2 billion landmark verdict in the Roundup cancer case of Pilliod et al. v. Monsanto. The verdict was #1 in California and #2 in the U.S. in 2019 and is #9 in American history.

  • Super Lawyers
    Super Lawyers

    Super Lawyers is a rating service of outstanding lawyers from more than 70 practice areas who have attained a high-degree of peer recognition and professional achievement.

  • AV Preeminent Peer Review Rated
    AV Preeminent Peer Review Rated

    An AV® rating reflects an attorney who has reached the heights of professional excellence. The rating signifies the highest legal ability, and very high adherence to professional standards of conduct, ethics, reliability, and diligence.

  • Board Certified Attorneys
    Board Certified Attorneys

    The National Board of Trial Advocacy is one of the nation’s largest and oldest private board-certification organizations for attorneys. Two of our shareholders are certified in multiple specialties.

  • Top Jury Verdict in <br> CA and USA
    Top Jury Verdict in
    CA and USA

    TopVerdict.com ranks our $2 billion verdict in Pilliod et al. v. Monsanto as the biggest verdict in California and the second largest verdict in the U.S. in 2019. It is the ninth largest verdict in U.S. history.

  • Lawdragon 500 Leading Plaintiff Consumer Lawyers
    Lawdragon 500 Leading Plaintiff Consumer Lawyers

    Published annually, the Lawdragon 500 Leading Plaintiff Consumer Lawyers list recognizes the “best of the best” in this area of the law through nominations, research, and review by a board of their peers.

  • Multi-Million Dollar Advocates Forum
    Multi-Million Dollar Advocates Forum

    Multi-Million Dollar Advocates Forum is one of the most prestigious groups of trial lawyers in the United States.  Membership is limited to attorneys who have won million and multi-million-dollar verdicts and settlements.

  • Product Liability Practice Group of the Year
    Product Liability Practice Group of the Year

    In 2020, Law360 honored the law firms ”behind the litigation wins and major deals that resonated throughout the legal industry.” It recognized our success in several landmark cases.

  • Top Personal Injury Jury Verdict in California
    Top Personal Injury Jury Verdict in California

    In 2018, our $289 million Johnson v. Monsanto verdict was the largest personal injury verdict in California. TopVerdict.com also ranked it #2 among all verdicts in California and #10 in the nation.

  • Bar Register of Preeminent Lawyers
    Bar Register of Preeminent Lawyers

    The Bar Register is the definitive guide to the most distinguished law firms in America. It includes only those select law practices that have earned the highest rating in the Martindale-Hubbell Law Directory and have been designated by their colleagues as preeminent in their field.

/

Firm Reviews

What Our Clients Are Saying
  • I Can’t Imagine a Better Law Firm

    “Multiple lawyers recommended Baum Hedlund to me and I have been consistently impressed with the quality of their work.”

    - Best Law Firms Survey
  • They Are About Changing the Systems...

    “Baum Hedlund are not only amazing attorneys but more importantly, they are activists. They are about changing the systems which got us into trouble in the first place. They understand their role in the process of making change.”

    - Kim Witczak
  • Top Legal Minds in the Country

    “The Baum, Hedlund firm has some of the top legal minds in the country; they are driven, determined, trustworthy, ethical and passionate.”

    - From Best Lawyers® Best Law Firms
  • Diligent & Professional Representation

    “Thanks to your efforts I was able to recover from a tragic experience and turn my life around for the best.”

    - W.T.
  • Our Best Interest Was Always Number One on Your List

    “A special thank you to your Spanish-speaking staff for the extra effort put into this case. The language barrier was never a problem, and we are so very thankful to them. Your name holds much respect in our family.”

    - G.C. & C.C
/