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Medicare and Medicaid Fraud

“Lessons from Health Care Fraud in Medicare and Medicaid” to Begin on This Whistleblower Lawyer Blog

May 8, 2007
Michael Sullivan

Because health care fraud in the Medicare and Medicaid programs is such a huge problem, this week our whistleblower lawyer blog writers (former federal prosecutors who are now whistleblower attorneys) begin a series of posts on “Lessons from Health Care Fraud in Medicare and Medicaid.”

We will discuss how whistle blowers in the medical services profession have been important resources in revealing and stopping health care fraud in hospitals, nursing homes, physicians’ practices, and the pharmaceutical or drug industry. We also discuss how the
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Whistleblower Lawsuit Against California Hospital Accused of Overbilling is Settled

April 30, 2007
Michael Sullivan

In a whistleblower lawsuit settlement, the Loma Linda Behavioral Science Center agreed to pay more than $2 million to resolve allegations of overbilling.

This False Claims Act whistleblower case was filed by a former employee of Healthcare Financial Advisors (HFA), a consulting firm that advises hospitals in preparing cost reports. The lawsuit alleges that HFA assisted its clients in seeking reimbursement for unallowable costs from Medicare and Medi-Cal.

Justice Department Announces It Joins Qui Tam Health Care Fraud Cases Against HealthEssentials Solutions Inc.

April 26, 2007
Michael Sullivan

Health care cases remain busy this week. The Justice Department on April 26 announced that it is joining whistleblowers in pursuing three qui tam lawsuits against HealthEssentials Solutions Inc. (HES) that allege false claims were submitted to Medicare.

The cases involve allegations of upcoding — improperly using a diagnosis code that is not supported by the medical record, for the purpose of obtaining greater reimbursement–and billing for medically unnecessary services.

The three cases were filed separately in the U.S. District Court in Louisville, Ky., by
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Medicare Fraud Indictments in Los Angeles

February 20, 2007
Michael Sullivan

We find it staggering to read about how blatant Medicare fraud can be, which often provokes a whistleblower to step forward. Today’s L.A. Times reports on a shameless scheme to defraud Medicare:

Elderly and mentally ill patients allegedly were offered doughnuts, candy and other gifts to lure them into more than $12 million worth of unnecessary respiratory treatments that were fraudulently billed to Medicare, according to the Indictment. Doctors and administrators were charged, according to this report.

What can you say about such criminality,
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State Enforcement Efforts Disappointing In Combatting Medicaid Fraud

February 2, 2007
Michael Sullivan

According to a recent report issued by the Inspector General of the Department of Health and Human Services, State enforcement results regarding Medicaid fraud cases have been disappointing. Virtually every state in the country has a State Medicaid Fraud Control Unit whose principle job is to uncover and detect fraud and to prosecute the offenders. Such units are also tasked with the responsibility of attempting to recover monies fraudulently obtained from the Medicaid program. Because Medicaid is approximately twenty (20%) percent of the total federal
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Government Joins Whistleblower Case Against Pharmaceutical Firm for Overcharging on Generic Drugs

February 1, 2007
Michael Sullivan

We saw another significant whistleblower case against a drug company hit the news wire this week.

The government announced that it was joining a qui tam lawsuit under the False Claims Act against the company Boehringer Ingelheim Roxane, Inc. The Complaint alleges overcharging on pharmaceutical products.

In joining this lawsuit, the United States has alleged that the drug company engaged in a “scheme to report fraudulent and inflated prices for several pharmaceutical products, knowing that federal health care programs established reimbursement rates based on those reported prices.”

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Why States Are Passing Their Own Qui Tam Whistleblower Laws

January 24, 2007
Michael Sullivan

I looked into the experiences that states have had with their own False Claims Acts, because almost every state is considering passing its own. I have tried to provide a brief summary that I hope is useful to you.

To encourage states to enact their own False Claims statutes with qui tam whistleblower provisions that are at least as effective as the federal Act, Congress created a large financial incentive when it passed the Deficit Reduction Act of 2005. States that have or enact such acts become eligible as of January 1, 2007, for a 10% increase in the state’s share of Medicaid fraud recoveries.

Many states, therefore, will consider whether to follow suit by enacting their own False Claims Act as early as 2007. Thus, it is important to consider other states’ experiences with their own state statutes governing false claims.

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No More Gifts For Doctors

January 22, 2007
Michael Sullivan

The International Federation of Pharmaceutical Manufacturers and Associations revised its Code of Ethics on January 1 of this year for the first time in a decade. Under the newly revised Code of Ethics, members of the trade group which represents pharmaceutical companies worldwide may no longer provide “expensive gifts” or paid trips to physicians. While the code allows members to provide physicians with gifts that are related to prescription drugs that are inexpensive such as pens, paperweights, stethoscopes and other de mini’s gifts, the new

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