The healthcare industry plays a crucial function in society allowing the population access to medical services in times of illness, illness prevention and other matters like end of life dignity. The United States has made healthcare services more accessible to the American population through federally funded programs like Medicare and Medicaid. No matter what your political opinion is of the program, they assist with individuals accessing health care who ordinarily may not be able to. Unfortunately, there are many service providers, doctors, hospitals, and other facilities who are taking advantage of government health care systems through fraudulent activities, which include over-billing, kickbacks and other schemes that harm the system. This, in turn, means these individuals and organizations are robbing the government, as well as the U.S. taxpayers, of their money.
In the last eight years, more than $2 billion a year has been recovered by the Department of Justice on an annual basis after cases were filed against companies who conducted illicit activities that harmed the government. In the first half of the 2016 Financial Year, there were 383 civil actions, along with 428 criminal actions recorded that affected Medicare and Medicaid combined.
Whistleblowers serve a vital role to play in helping the government and the Department of Justice recover funds that were illegally stolen from them through fraudulent activities by companies in the healthcare and pharmaceutical industries. The False Claims Act (FCA) allows people to come forward with such information and, in turn, gain a percentage of recovered funds as a reward for being the whistleblower in a Qui Tam lawsuit with the use of a whistleblower lawyer, such as Brown, LLC.
Parties Responsible for Fraud in The Healthcare Industry
It is important for individuals to understand that anyone in the healthcare industry can commit fraud that has a negative impact on the federally funded programs. There are many types of insitutions, officials, and even individuals that may conduct such fraud – and employees need to understand when they might have a whistleblower case and the signs to look our for to determine whether there is medicare fraud or Medicaid fraud.
- Hospitals –
When a hospital bills a patient’s Medicare or Medicaid for services that were not provided to the patient or when they provide a patient with unnecessary services, it means they are conducting illegal activities. Some hospitals also tend to admit a patient into the hospital when the patient only required outpatient treatment. In California and Illinois, if private insurance is defrauded, there is a mechanism for whistleblowers to bring a private action as well.
- Physicians and Medical Providers –
Medical service providers like psychiatrists and physicians may claim funds from Medicare or another health care agency for services they did not provide a patient, or they may conduct double billing, where the bill for two sessions when the patient only had a single appointment. Many medical service providers have also been found guilty of upcoding services when they claim from a federally funded medical program, which means they provide one service to a patient but claim for a similar service that holds a higher fee. They may also engage in kickbacks (paying for referrals) which violate the Anti-Kicbkack Statute (AKS) or self-dealing where the physician refers the patient to a pharmacy or some other entity he or she owns without disclosing it (Stark Act) violations.
- Pharmaceutical Companies –
Companies that manufacture pharmaceutical drugs, are sometimes found to participate in off-label marketing strategies and sell drugs for purposes other than what they were developed for. In some cases, pharmaceutical companies have been found guilty of manipulating data from clinical trials in their favor or adulterating drugs to pass quality testing.
- Pharmacies –
Pharmacies may sometimes bill the patient’s medical aid provider for prescription drugs that were not provided to the patient. In some cases, pharmacies may over-bill the insurance agency or falsify prescriptions for a patient. These are all fraudulent activities.
- Medical Device Manufacturers –
There have been cases where manufacturers of medical devices charge a client’s medical insurance program for unnecessary devices, they charge for more expensive devices than what was provided to the patient, or they provide the patient with defective devices and charge Medicare or Medicaid for these devices.
These are, of course, only a few examples of service providers in the healthcare industry where fraud is often detected. There are many other examples as well – all areas of healthcare can become fraudulent in reality.
Reporting Healthcare Fraud as A Whistleblower
A large number of fraudulent activities can be reported by whistleblowers when they become aware of such activities conducted by a health care provider, a hospital, or another service provider. The law does not allow one to receive a recovery unless they blow the whistle correctly which requires the use of a whistleblower attorney.
Some fraudulent activities that employees should keep an eye out for in the workplace:When doctors, hospitals, and other medical services providers upcode the services or devices provided to patients in order to gain additional funds from a health care program.
- When doctors, hospitals, and other medical services providers upcode the services or devices provided to patients in order to gain additional funds from a health care program.
- When a service provider is provided incentives to prefer one product or service over another, such as a specific type of medication or a specific laboratory.
- When a physician, therapist, or any other medical service provider charges a patient’s medical aid for services or treatments that the patient was not provided.
- When pharmaceutical companies ask their reps and employees to conduct off-label marketing.
When any of these activities occur, or other fraudulent activities are detected, an employee should come forward with the information by contacting an experienced whistleblower attorney like Jason T. Brown, a former FBI special agent who represents whistleblowers. Whistleblower awards average around 20% of the recovery which could be a considerable recovery for the government and the whistleblower.