If you have knowledge about medical billing fraud, contact the experienced whistlebower attorneys at Newman & Shapiro. Medical billing fraud is endemic to the healthcare industry, costing somewhere on the order of $60 to $100 billion annually. Not only are taxpayers defrauded through false and inaccurate claims to the federal government, but patients suffer from higher prices as a result.
Whistleblower qui tam lawsuits filed through the False Claims Act (FCA) are the single most effective tool against this fraud. However, many doctors, nurses, and others in the healthcare profession are afraid to speak out for fear of retaliation. The good news is that the FCA protects employees by outlawing workplace retaliation in the event they expose wrongdoing. The statute also provides rewards for whistleblowers, which in some cases can be substantial.
How Does Medical Billing Fraud Work?
Healthcare fraud comes in many forms, but medical billing is arguably the most widespread. Dishonest individuals and companies working in the healthcare field have devised numerous strategies for committing billing fraud against federal healthcare programs. Some of those methods include:
- Billing for services and supplies that were never rendered to the patient
- Double billing, which is billing twice for the same services or supplies
- Billing for unnecessary medical procedures
- Upcoding, where healthcare providers bill for more expensive treatments and services than what the patient received
- Unbundling, which is billing more for individual tests and procedures that are supposed to be bundled together
- Submitting reimbursement requests for costs other than direct patient care (e.g. capital improvements) that the government does not cover
- Marketing medical devices or prescription drugs for non-approved purposes
- Kickbacks, referral fees, finder’s fees, and the like
These and other billing schemes typically involve healthcare programs such as:
- Medicare (provides insurance and healthcare services to individuals 65 years of age and over, and patients with certain disabilities)
- Medicaid (provides insurance and healthcare services to low-income individuals)
- TRICARE (military healthcare program formerly known as CHAMPUS)
Medical billing fraud is rampant because of the sheer scope of these federal programs and the amount of money they pay out. It’s nearly impossible for anyone working in the government to detect fraud unless a whistleblower alerts them to it. On top of that, many billing schemes are wrapped up in confusing and obscure medical jargon which only someone in the healthcare profession would understand.
Who May Be A Medical Billing Fraud Whistleblower?
It’s not uncommon for healthcare professionals and employees to be threatened with job loss if they refuse to submit fraudulent medical bills. That’s one reason the employment retaliation provisions of the FCA exist. Whistleblowers are protected from being discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against for taking appropriate action to expose fraud.
Since medical billing fraud covers a wide range of activities across several federal healthcare programs, there are numerous individuals who could be whistleblowers. They include:
- Medical sales representatives
- Hospital administrators
- Benefit coordinators
- Coding specialists
If you are one of these individuals or someone else with information about fraudulent medical billing, it’s important to explore whether you may be eligible to file a qui tam lawsuit under the FCA.
Why Would I Want To Be A Whistleblower?
In addition to uncovering fraud and protecting both taxpayers and patients, whistleblowers who file FCA lawsuits are eligible for potentially significant rewards. These rewards range from 15 to 30 percent of the funds recovered by the government. The actual reward amount will vary based on a number of factors, such as the value of the information provided and the assistance the whistleblower and his or her counsel provide. In some cases, damages are tripled and can reach substantial sums. Having a knowledgeable medical billing fraud attorney is imperative to securing the highest reward possible.
How Do I Qualify To Be A Whistleblower?
Not everyone who knows about medical billing fraud can be a whistleblower. In order to file a qui tam lawsuit, you must:
Have non-public, tangible evidence of fraud. Learning about fraud through the media or as a result of a government investigation or audit does not count.
Document your evidence with sufficient detail. You are required to detail the evidence you have to the government, and it needs to be enough to justify legal action for fraud.
Be the first to step forward with the information. The FCA is a first to file statute, which means if someone else with the same evidence files before you, your claim is invalid.
File a qui tam lawsuit under the FCA. Qui tam lawsuits are exceptionally complex, so you should consult an attorney who has extensive experience with this unique area of law.
How Do I Get Started?
If you have original information about medical billing fraud and believe you meet the above criteria, it’s important to take action as soon as possible. Not only does immediate action help you secure first to file status, but statutes of limitations may apply which place a deadline on your ability to file.
When you contact our firm, we will schedule a confidential consultation with you to review the evidence you have and let you know if you qualify to be a whistleblower. If so, we will help you file a qui tam lawsuit. These lawsuits are filed under seal in United States District Court, during which time the government will investigate your allegations. Therefore, you should only discuss the case with your attorney.
Contact Our Healthcare and Medical Billing Fraud Attorney Today
The FCA has strict procedural and substantive provisions which, if not followed, can invalidate your lawsuit and your ability to claim a reward. Working with the right attorney, however, you can help put an end to medical billing fraud. Don’t risk taking on one of these lawsuits by yourself. Contact Newman & Shapiro today.