Common Health Care Fraud Schemes
Some of the most common fraudulent activity committed by some nursing homes, health care, and other medical facilities include:
- Billing Medicare/Medicaid for services that were not provided: some dishonest health care providers bill the Medicare and Medicaid programs for services that were not provided. This cheats taxpayers out of money and deprives patients of resources they need.
- Billing for ineligible patients and services: some health companies illegally bill Medicare/Medicaid
- Substandard care: facilities and companies that provide health care and bill the Medicare/Medicaid programs must meet a certain level of care with their services. Some companies provide substandard care by, for example, having unqualified personnel work for them or failing to make licensed personnel available.
- Overbilling Medicare/Medicaid for visits: health clinics bill Medicare for services by selecting codes that are divided into five levels from basic (level 1) to most complex (level 5). Higher level codes result in higher payment from Medicare than lower level codes. Unscrupulous health care companies select codes services that exceeded those that were actually provided in order to fraudulently increase the amount of payment it receives for patient visits.
- Illegal kickbacks: in federal health care programs, paying physicians for referrals is illegal. Some nursing homes, substance abuse programs, home health care companies, and others have settled with the government for millions after giving kickbacks and compensation to referring physicians. Whistleblowers have been compensated with a portion of these monetary recoveries for risking their reputations and bringing these illegal schemes to the law enforcement authorities’ attention.
Pursuing Health Care Fraud is a Government Priority
Stopping healthcare and Medicare fraud is a priority for the U.S. Department of Justice. In May 2009, the DOJ and the Department of Health and Human Services created the Health Care Fraud Prevention and Enforcement Action Team (HEAT). The task force’s mission is to prevent the waste, fraud, and abuse of Medicare and Medicaid programs that cost American taxpayers billions of dollars each year. The HEAT task force is a multi-government agency team comprised of state, federal, and local investigators with the goal of stamping out health care fraud and waste.
Since 2008, actions by the HEAT task force led to a 75% jump in individuals charged with criminal health care fraud. The HEAT task force and other government actions indicate that law enforcement officials are placing an emphasis on eliminating health care fraud. As a whistleblower represented by The Cochran Firm, D.C.’s whistleblower attorneys, you can help the government root out and eliminate health care companies that are cheating taxpayers out of millions of dollars.
In January 2014, David Hale, the U.S. Attorney for the Western District of Kentucky, noted that “pursuing health care fraud is a priority of [his office] and the Department of Justice.” He said that the DOJ will “continue to work with the Department of Health and Human Services and the public to ensure that fraudulent claims are investigated and those responsible are required to pay.”
Medicare/Medicaid Fraud Whistleblower DOJ Settlements
In 2014 alone, some recent successful whistleblower claims made against health care, nursing home, and other medical care facilities that settled with the DOJ include:
- Amedisys Home Health Companies: $150 million to settle allegations of submitting false home healthcare bills to the Medicare program.
- CRC Health Corp.: the substance abuse treatment facility agreed to pay $9.25 million to settle allgeations that it knowingly submitted false Medicaid claims by providing substandard mental health treatment to adult and adolescent patients suffering from drug and alcohol addiction. The whistleblower in this case received $1.5 million as her share of the settlement proceeds.
- American Family Care: $1.2 million to settle charges the walk-in medical clinic company overbilled Medicare
- Memorial Hospital: $8.5 million to settle claims the acute care hospital gave kickbacks to referring physicians
- Diagnostic Imaging Group: $15.5 million to settle claims that it falsely billed federal and state health care programs for tests that were either not performed or were not necessary and allegations that it paid kickbacks to doctors. Three whistleblowers in the case received $1.5 million, $1.07 million, and $209,250, respectively.
- Omnicare: $4.19 million to resolve charges that it solicited and received kickbacks from drug maker Amgen in exchange for creating therapy programs that were designed to switch Medicaid beneficiaries from a competitor drug to Amgen’s drug Aranesp.
- EndoGastric Solutions: $5.25 million to settle claims that it caused health care providers to bill for its less invasive EsophyX procedure using billing codes applicable to more invasive and expensive procedures. EndoGastric was also accused of paying illegal kickbacks to physicians for participating in patient seminars and co-marketing agreements to induce them to use its EsophyX device used to treat gastroesophageal reflux disease. The whistleblower in this case will receive up to $945,000.
- SelfRefind and PremierTox: $15.75 million for allegations it submitted claims to Medicare and Kentucky’s Medicaid program for medically unnecessary tests.
- Saint Joseph Health System Inc.: $16.5 million to settle claims it submitted false claims to Medicare for a variety of unnecessary cardiac procedures.
- Tennessee Orthopaedic Clinics and Appalachian Orthopaedic Clinics: $1.85 million to settle allegations they purchased deeply discounted osteoarthritis medications that were reimported from foreign countries and billed them to state and federal health care programs. These medications, known as viscosupplements, are not reimbursable because they are reimported. The private citizen who blew the whistle on this activity received $323,750.
- Former HealthEssentials Solutions CEO Michael R. Barr: more than $1 million to settle claims he knowingly caused HealthEssentials to submit false Medicare claims. The whistleblowers in this case will receive $153,000 for their efforts.
- CareFusion Corp: $40.1 million to settle claims that it paid kickbacks to a doctor and promoted its products for uses not approved by the Food and Drug Administration. The whistleblower’s share in this qui tam claim was $3.26 million.
- RehabCare Group, RehabCare Group East, Rehab Systems of Missouri, and Health Systems Inc.: $30 million to resolve claims they engaged in an illegal kickback scheme related to the referral of nursing home business. The whistleblower in this case received $5.7 million for blowing the whistle on this allegedly fraudulent activity.
Contact an experienced health care fraud whistleblower lawyer
The experienced attorneys with The Cochran Firm, D.C. understand the medical industry and the types of fraudulent schemes perpetrated by unscrupulous health care companies. We offer free, confidential consultations with no obligation and no pressure to individuals who are considering blowing the whistle on fraudulent activity in the health care industry. Because strict time limits apply to filing whistleblower claims, we recommend contacting us as soon as possible in order to determine your options.