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Whistleblowers and the Healthcare Fraud Epidemic

The government spends more than $1.3 Trillion on Medicare and Medicaid every year.  Of that amount, the government estimates that between $60 Billion and $100 Billion is lost to fraud, waste, and abuse.  Yes, that is $60 to $100 Billion with a capital B.

Most of the fraud is difficult to detect.  For example, you might be treated by a physician’s assistant at an urgent care center, but they billed Medicare as if you were seen by a more expensive physician.  Since the person who treated you wore a white coat and had a stethoscope around his neck, you might never know that the urgent care center committed fraud.

Or you might have a 45 minute session with a therapist, but they billed Medicaid for a full hour.  When your explanation of benefits arrives, you don’t notice how much time they billed because the bottom line says that you do not have to pay anything.

Or your physician received a small kickback from the diagnostic lab where he referred you, which is illegal and renders any claim for reimbursement fraudulent.

These may seem like minor frauds.  But to paraphrase a famous politician, when you are dealing with a $1.3 Trillion budget, 5% fraud here and 10% fraud there quickly adds up to Billions of dollars in fraud.

How can the government possibly discover these types of fraud when there are tens of thousands of healthcare providers across our very large country?

That is where whistleblowers come in. Doctors, nurses, billing staff, and even patients can earn very large rewards for helping the government discover healthcare fraud.

The False Claims Act allows anyone with evidence of fraud to become a whistleblower and qualify for a reward.  A whistleblower lawyer will help you prepare a complaint that is filed “under seal” (i.e., in secret).  Your lawyer will then help you present your evidence to the government, which will conduct an investigation and decide whether to pursue claims against the fraudsters.  And if the government recovers money as a result of your help, you will receive a reward of between 15% and 30% of the amount the government recovers.

While some whistleblower cases result in multi-million dollar rewards, even the most routine cases can result in substantial rewards.  Here are a few whistleblower settlements that were announced on just one day this week:

  • A Florida nursing center paid $1.5 million to settle Medicare fraud charges, resulting in a whistleblower reward of more than $255,000
  • A Kansas pharmacy paid $9.5 million to settle Medicaid fraud charges, resulting in a whistleblower reward of more than $1.6 million
  • A Tennessee dialysis center paid $3.25 million to settle claims of paying illegal kickbacks to doctors, resulting in a whistleblower reward of more than $550,000
  • A Texas pathology lab paid $64 million to settle claims of paying illegal kickbacks to doctors, resulting in a whistleblower reward of more than $10 million

These settlements are only the tip of a very large iceberg.  Every year, the government recovers approximately $3 Billion as a result of whistleblowers coming forward to report fraud.  That amounts to less than 5% of the fraud the government estimates exists.

It is obvious that much more work needs to be done.  If you have evidence of Medicare or Medicaid fraud, you should consult with a lawyer immediately to determine if you might be eligible for a reward and legal protections.

 

To speak with an experienced whistleblower lawyer, call John Howley, Esq. today at (212) 601-2728.

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