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Whistleblowers Receive Financial Rewards for Reporting Healthcare Fraud

Medicare Fraud

Whistleblowers have assisted government entities in recovering record setting amounts of federal funds, especially by reporting healthcare fraud and filing claims under the False Claim Act (FCA).

The Department of Justice (DOJ) recovered more $9.5 billion from 2009 through 2012, primarily by using the FCA to pursue frauds pertaining to Medicare and Medicaid.  In 2012 alone, the DOJ recovered almost $2 billion in false claim cases involving drugs and medical devices and whistleblowers received awards of $439 million and in fiscal 2013, the DOJ recovered $2.6 billion.

Healthcare whistleblowers can receive up to 30% of the amount recovered by the government in connection with a qui tam lawsuit filed under the FCA.  Whistleblowers have received awards for assisting the government in pursuing healthcare fraudsters who employed various methods to cheat the government, including the following:

  • Upcoding: health service provider uses a more expensive billing code than the code for the actual service provided.
  • Unbundling: billing related services separately to improperly receive a higher reimbursement when those related services should be billed under a single code.
  • Kickback: financial compensation given to a doctor or hospital in exchange for referrals or prescribing certain medications.  Laws prohibiting kickbacks are intend for doctors to prescribe medications based on patient needs rather than financial incentive.
  • Off-label marketing: submission of false claims to Medicare and Medicaid for reimbursement of expenses for prescription medications or medical devices which have not been approved by the Food and Drug Administration (FDA).
  • Falsification of medical records: submitting claims to Medicare or Medicaid for services or supplies which are not medically necessary or were never provided.

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Milberg Tadler Phillips Grossman LLP
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