President Trump made the “repeal and replacement” of the Affordable Care Act a centerpiece of his Presidential Campaign and Presidency. Thus, as Congress has attempted to “repeal and replace” “Obamacare,” the costs associated with health care have become a major focus of national attention. Such costs, and which party will bear them, are crucial issues currently being considered by Congress as it reevaluates the Affordable Care Act.
The federal False Claims Act is the statute that enables people with knowledge of false statements related to payment from such programs as Medicare and Medicaid assist the government by identifying these false statements and enabling the government to recover funds that should not have been paid.
The purpose of the False Claims Act, also referred to as the Qui Tam law, is to recover monies fraudulently billed to and paid by the government. Whistleblowers are people who assist the government in proving how federal and/or state dollars have been paid because of healthcare fraud. To encourage people to become whistleblowers, The Federal False Claims Act rewards the whistleblower for assisting the government in identifying the false statements that cause the government to pay a Medicare and/or Medicaid bill by awarding the whistleblower from 15% to 30% of the funds recovered because of the false statement included in the billing or report.
Because of their insider knowledge of the industry, health care workers such as physicians, nurses, physical therapists, laboratory technicians, hospital and physician office staff, home health care aides, nursing home staff, hospice staff, and billing staff are in an ideal position to be whistleblowers. Whistleblowers help the government recover funds procured by private companies as a result of false statements related to medical treatment and services. The health care industry should be concerned with people’s physical and mental well-being, but often the profit motives of doctors, hospitals, laboratories, physical therapists, nursing homes and pharmaceutical companies supersede the obligations to the patients.
The following are some potential examples of healthcare fraud:
- An employee of a physician’s office may observe that the physician is charging Medicare and/or Medicaid for two doctor’s visits when in fact, the patient only had one visit. This is known as “double billing.” The request for funds received for a second visit that did not actually occur may be considered a false claim for payment. Similarly, an employee of a laboratory may note that a patient has been charged for two blood tests when only one blood test was performed, or charged for two X-rays when only one X-ray was performed. Such double billing may also be a violation of the False Claims Act.
- Doctors or physical therapists may fraudulently use a patient’s personal information to claim that they have prescribed a wheelchair for a patient, even though the patient never needed or received the wheelchair. Therefore, the Government health insurance plan might pay for a wheelchair that was either unnecessary or not delivered to the patient, or both. The doctor or physical therapist, and potentially the wheelchair company, share the Medicare or Medicaid payment, and the patient never knows that his or her personal insurance information was used in this way. The bill submitted to the Government is a false statement subject to penalties under the False Claims Act.
- Hospitals may admit Emergency Room patients for inpatient care even though the patient’s medical condition does not require such an admission. As inpatient care often creates higher income than treating and releasing a patient from the Emergency Room, hospitals increase their income as a result of such medically unnecessary admissions. This may be considered a false statement as it results in overbilling for unnecessary treatment.
- Patients may be referred by a physician for hospice care when the patient’s condition does not justify such a placement. Such a referral may be considered a false statement.
- As the American population ages, there is an increasing need for home health care. Those medical providers who provide such care are entitled to bill Medicare and/or Medicaid for the actual services that the patient needs and is provided. It may be considered a false statement to bill Medicare and/or Medicaid for services that the patient needs but are not actually provided by the Home Health Aide, although such services were prescribed.
- It may be healthcare fraud for an unlicensed or unqualified Physical Therapist to bill for therapy provided by a person who is unlicensed or unqualified to provide such therapy.
These are just a view examples of behavior that may be considered healthcare fraud pursuant to the False Claims Act. Given their roles in the industry, healthcare workers are uniquely positioned to witness these types of fraudulent schemes. In fact, because healthcare workers are sometimes forced by their employers to take part in these schemes, the employees are often intimately familiar with the details of the fraud. The employees are often still eligible for a whistleblower reward despite their involvement. Ultimately, due to the pervasiveness of healthcare fraud in America, the Government needs the assistance of all types of healthcare workers in its effort to recover Medicare and Medicaid payments that should not have been paid because of healthcare fraud.
Sanford Heisler Sharp employs attorneys who specialize in representing whistleblowers pursuant to the False Claims Act in each of our offices: Washington, DC, New York City, San Francisco, San Diego and Nashville. Many of our whistleblower attorneys have extensive experience particularly related to fraud in the healthcare sphere.