What is a Medicare Whistleblower?

When it comes to Medicare fraud, whistleblowers are the government’s first line of defense in the fight against prevalent fraud in the healthcare industry. Medicare fraud is a huge waste of taxpayer dollars and can ultimately lead to inappropriate care for innocent individuals. Even with the assistance of numerous whistleblowers and lawsuits and the recovery of billions of dollars, there are still billions that are never detected or recovered.

If you have become aware of a scheme meant to defraud the Medicare program, you may be able to act as a whistleblower. The experienced whistleblower attorneys at Khurana Law Firm can help.

Using tools like the federal False Claims Act or state false claims acts, the legal system has been able to hold healthcare providers who use fraudulent practices to steal from essential agencies like Medicare accountable. Using important whistleblower laws, individuals who come forward to report fraudulent activity have been critical in our nation’s fight to combat healthcare fraud.

The Prevalence of Medicare Fraud

Unfortunately, fraud is easily perpetrated against huge government healthcare programs such as Medicare. While systems for billing the program are meant to be easy and efficient, they are also easy targets for fraud. Unfortunately, undeserving providers can enter the system. Even large, well-known Medicare Advantage programs have been found defrauding the system to obtain higher reimbursements from Medicare.

A Medicare whistleblower is someone who is aware of fraudulent activity and agrees to come forward to file a civil lawsuit against the entity or provider committing the fraud. This is usually done under the federal False Claims Act or a similar state act. The government has the right to enter into the suit in order to recover its losses, or the individual whistleblower can go forward with the suit alone. There are substantial rewards available to these individuals if the lawsuit is successful.

Who Can Act As a Medicare Whistleblower?

When an employee of a healthcare facility, institution, organization, provider, or outside contractor or consultant becomes aware of activity meant to defraud the Medicare program, they have rights and protections under the law. But convincing the government to pursue these cases requires substantial evidence. Consequently, most whistleblowers are individuals who work within the company or organization they are reporting. Because these individuals have inside information regarding the fraudulent activity, their chances for success are much greater.

These individuals are eligible to receive rewards of between 15 percent and 30 percent of any funds the government obtains in the suit, providing the information they report is original information that leads to successful prosecution. Furthermore, these individuals are protected under the False Claims Act from any retaliation by their employer.

Whistleblowers have filed lawsuits under the False Claims Act for many types of fraudulent activities, such as

• Billing for unnecessary services
• Billing for things that were not used
• Unbundling services
• Upcoding services
• Chart mining
• Fraudulent risk adjustments
• Misdiagnosing
• Improper reporting
• Kickbacks
• Providers who are financially incentivized
• Illegal pharmaceutical marketing
• Compliance failures
• Pharmaceutical diversion
• Collusion
• Improper treatment of nursing home residents

If you are aware of activity that is used to defraud the federal Medicare program, you should get legal advice concerning your next move. At the Khurana Law Firm, P.C., our experienced whistleblower attorneys have dedicated our careers to representing those courageous individuals who come forward to report Medicare fraud. To get professional legal guidance, call us at (888) 335-5105 or contact us online to schedule a confidential, no-cost consultation.

source https://medicarewhistleblowercenter.com/what-is-a-medicare-whistleblower/

What kind of reward might a healthcare whistleblower receive?

There are many factors that come into play when it comes to receiving a reward for bringing forth a successful whistleblower lawsuit. Rewards are dependent on the type of case and what particular program or act the suit or claim is filed under. For instance, there are specific guidelines that determine if a whistleblower case is to be filed under The False Claims Act, Securities and Exchange Commission, Commodity Futures Trading Commission, or the IRS. The most common whistleblower cases (also known as a qui tam lawsuit), that originate from the healthcare industry, usually involve fraud against the Medicare or Medicaid systems. Individuals who have evidence of Medicare or Medicaid fraud may be eligible to receive monetary compensation as a reward under The False Claims Act. Bringing your case to a healthcare whistleblower lawyer will help you stay protected from any potential retaliation and assist you in putting forth a strong case.

What does the potential compensation look like for a healthcare whistleblower?

No matter what whistleblower program a claim is submitted under, rewards are a certain percentage of the amount of money that is recovered for the government, not the total amount of money that the government has lost. Specifically, whistleblower cases under the provisions of The False Claims Act, could receive anywhere between 15% – 30% of the total amount recovered. There are, however, other factors that help determine the actual percentage that will be the reward to the whistleblower, includiing whether or not the government joins the case, the strength of the evidence that’s supporting the false claim, and ultimately, the support that’s put into the case by the whistleblower and by the lawyer that is representing the whistleblower’s case.

What could compensation look like if the Government decides to join the case?

When a lawsuit is brought forth under The False Claims Act, the next step would be for the Government to initiate its own investigation of the presented case. Once the case has been investigated, the Government will then decide if they’d like to step in as the plaintiff in the case. If the government joins the case, the expected reward is 15% – 25% of the recovered funds, with the additional consideration of the aforementioned contributing factors. If the government decides not to take on the case, and if the whistleblower decides to go ahead and move forward with the case, the whistleblower could then receive a reward of 25%-30% of recovery.

Who is responsible for paying for the reward of the whistleblower?

If a whistleblower lawsuit is successful, the federal government is responsible for paying the reward to the whistleblower. This will be a percentage of the total amount recovered to the government. The total amount recovered could include treble damages (which is an amount of $3 for every $1 the government lost as a result of the fraud) and penalties for the claim.

Arvind Bob Khurana, national whistleblower attorney, helps people from bringing forth healthcare-related fraud.

At Khurana Law Firm, it is a part of the firm’s mission to use their knowledge and resources to build a strong case that will help whistleblowers receive a reward for aiding the government to fight against fraud. Contact us today for a consultation.

source https://medicarewhistleblowercenter.com/what-kind-of-reward-might-a-healthcare-whistleblower-receive/

What is upcoding and why is it illegal?

When a medical professional treats a Medicare patient, the provider must report what services were provided to make sure Medicare reimburses the doctor appropriately for the services rendered. Certain conditions are more severe than others and require more costly care, which may mean that doctors can receive higher reimbursements from Medicare for treating these patients. In some cases, a healthcare provider may engage in upcoding – misreporting healthcare services or the severity of a patient’s condition, in order to receive higher reimbursement from Medicare. If you are a healthcare professional who is aware of potential upcoding in your work environment, it is vital to contact a healthcare whistleblower attorney immediately.

Whistleblower Attorneys Help Protect the integrity of the Medicare System

Medicare is the US government health insurance plan for people over the age of 65. When a medical provider provides services to an eligible Medicare patient, they submit an electronic form to Medicare that uses procedure codes (HCPCs) to tell them what services were provided. The process is efficient when providers certify their claims as true, accurate, and complete.

After submitting a claim for reimbursement, Medicare reviews the details of the claim and if approved, pays out accordingly. The Medicare system relies on the information submitted by providers. Providers are responsible for checking that they have used the correct procedure code and have performed all of their services correctly. Providers are subject to less oversight because Medicare does not have the means to double-check all information submitted. Providers must be careful to submit accurate information to maintain a good reputation and avoid being excluded from the program altogether.

What does “upcoding” mean?

Upcoding or code manipulation refers to the act of purposefully misreporting the health care services provided in order to receive higher reimbursement from the insurance programs. Upcoding is a common form of Medicare fraud that classifies treatments as being more complex or costly than what would be needed to address an individual’s needs.

Medicare may pay out more money than is necessary to providers who perform services for Medicare beneficiaries because some healthcare providers will falsely bill Medicare by giving them a service that they didn’t really perform and claiming to have done so. For instance, if a physician performs a minor chest procedure but bills Medicare using the billing code for major heart surgery, they may have engaged in upcoding fraud.

The False Claims Act (FCA) imposes liability for fraudulent “upcoding” of claims.

The False Claims Act, established in 1863 to combat fraud against the government, prohibits individuals from submitting false or fraudulent claims. Under this law, those who sue can keep a portion of what is recovered if they have knowledge of alleged Medicare fraud. The FCA also provides incentives for private-sector whistleblowing by protecting healthcare workers from certain types of retaliation for reporting in good faith.

National Healthcare Whistleblower Lawyer

Medicare fraud negatively impacts everyone, but whistleblowers are heroes that effectively protect our healthcare system. When you become aware of Medicare fraud upcoding in your workplace, you need the advice of an experienced whistleblower attorney who can ensure that your claim is fully investigated and filed promptly and accurately.

At Khurana Law Firm, P.C., we have many years of experience as national qui tam lawyers that can help fight against Medicare fraud. For a free, confidential evaluation call (888) 335-5107.

source https://medicarewhistleblowercenter.com/what-is-upcoding-and-why-is-it-illegal/

What is a Qui Tam Lawsuit?

The False Claims Act was passed to target fraud in government contracting and against the government. Under this act, individuals with sufficient evidence that would otherwise be unknown to the government may file a qui tam lawsuit. The False Claims Act has been an effective way for people to help the government and American taxpayers recover funds that have been wrongfully claimed. A qui tam lawyer is an attorney that specializes in representing whistleblowers in qui tam cases and helps to protect the rights of the individual who brought the case forward.

Where did the term “qui tam” originate from and who can file a qui tam lawsuit?

The term “qui tam” is a Latin word that means “in the name of the King.” Originating in England, it provided a way for the general public to bring forth any violations against the law to the King and in return, that individual would be offered a reward. The federal False Claims Act was enacted in the US in 1863. As time passed the law has been amended and modernized into what it is today. Since 1986, the law has proven to be extremely effective towards anti-fraud. As society has changed, the individual who brings forth a qui tam lawsuit is more commonly referred to as a whistleblower or “relator.”

Anyone who has sufficient information of fraud against the government could contact an attorney and file a qui tam lawsuit. Most often, individuals who bring forth such cases are the employees or former employees of a company and the company itself is committing the fraud.

What is the best way to initiate a qui tam case and how does it work?

If you have information for a qui tam case, you should bring all the relevant information you have to an experienced and qualified attorney. From there, a qui tam lawyer will investigate further and if there is sufficient evidence, then present the case to the government. When filed, all details about the case would be kept completely confidential and it would not be of knowledge to the public. At this point, the government will conduct its own investigation into the case and decide whether or not to join the individual who reported the case. It wouldn’t be until that point that the defendant would be aware of the case and an announcement could be made to the public.

How will you be protected from retaliation from the defendant and what is the incentive to come forward?

Many qui tam cases end up resolved through the negotiation of a settlement outside of the courtroom. Settlements could be as much as three times the amount of monies lost and damages to the government. Sometimes the defendants in these cases may retaliate against the whistleblower but the False Claims Act has certain protections for those individuals. If a whistleblower can show that their employment relationship has detrimentally changed in retaliation to bringing forward their complaints, they may then have the right to file a claim of retaliation.

If the whistleblower initiates a qui tam case that results in a successful outcome, that individual would earn and receive a percentage of the monetary recovery in the case. There are many variables that determine the actual percentage that a whistleblower would receive and is always on a case-by-case basis, but nonetheless, many cases have resulted in large and substantial rewards.

False claims submitted in Medicare and Medicaid are the most common types of fraud brought under the qui tam lawsuits and it’s important to bring such cases forward to a qui tam lawyer who is highly experienced in these kinds of cases.

Although most Medicare providers and drug companies operate well within the regulated system, there are instances in which some entities choose to operate outside of the rules. When this happens, it ends up costing taxpayers. If you have information that may indicate fraud with Medicare or Medicaid, consider consulting a Medicare or Medicaid whistleblower attorney.

source https://medicarewhistleblowercenter.com/what-is-a-qui-tam-lawsuit/

Why is Medicare Fraud Such a Problem Today?

Today, health care fraud is ever-prevalent and continues to prove expansive. Medicare fraud encompasses many different types of activity, from billing for services that were not performed to miscoding. Consequently, the government relies heavily on whistleblowers and rewards them significantly for reporting fraud. This requires the skill of an experienced medicare whistleblower attorney to guide people through a claim to ensure that individuals and entities are held accountable.

How Medicare Works

Because Medicare is a vast government program, it must rely on many private companies to help administer operations. The CMS (Center for Medicare and Medicaid Services) contracts with these outside contractors to process claims and determine compliance with the rules. Consequently, these outside contractors are the ones who are responsible for payments from Medicare, interpreting the rules, and policing the industry within CMS professional practices.

An Easy Way to Perpetrate Fraud

Most health care professionals bill Medicare through an electronic claims submission system t. Although meant to be efficient, it also offers an easy way to perpetrate fraud.

If a Medicare provider has figured out a way to falsify claims and submit those claims through the electronic claims system or intentionally miscode to get higher reimbursements from Medicare, then these are examples of Medicare fraud that may lead to a whistleblower suit.

Is Medicare Too Big?

The Medicare system basically relies on trust with its providers. Because of the vastness of the program, it becomes ripe for fraud. With close to a billion claims filed annually, with many different carriers and a multitude of providers, policing the system and following up on claim validity is difficult. Consequently, investigators must focus on services where most fraud occurs, on system flags pointing to providers who overtly bill higher than others in their area, and on whistleblower claims under the False Claims Act.

Protection and Incentives Under the False Claims Act

The False Claims Act allows individuals to come forward when they have information about Medicare fraud and incentivizes this through a reward system for those people. Consequently, a successful whistleblower claim can recover substantial money for the government and also offer large rewards for a whistleblower if a recovery is made.

Getting Experienced Legal Advice

CMS rules can be extremely complicated. Consequently, someone who wants to file a whistleblower claim must get experienced and skilled guidance when pursuing a claim under the False Claims Act.

At the Khurana Law Firm, P.C., our skilled medicare whistleblower attorneys have dedicated our careers to representing those who come forward to play a critical role in detecting, reporting, and preventing Medicare fraud. We provide a confidential, no-obligation consultation to discuss your case and let you know if we think there is a viable case. You pay nothing unless there is a financial recovery. If you have knowledge of Medicare fraud, contact us to schedule an appointment.

The foregoing is for general use and is not legal advice. ATTORNEY ADVERTISING. PRIOR RESULTS DO NOT GUARANTEE A SIMILAR OUTCOME.

source https://medicarewhistleblowercenter.com/why-is-medicare-fraud-such-a-problem-today/