There have been many successful qui tam cases brought under the False Claims Act to report billing fraud. Individuals who work as billers or office managers will most likely come across healthcare billing fraud.
Qui Tam Settlements for Over Billing Medicare or Medicaid
In 2014, Wellcare Health Plans settled allegations of over-billing Medicare and Medicaid for $140 million. The whistleblower reported this healthcare billing fraud to the government. The government intervened and alleged that the company inflated expenses, falsified patient records, and operated sham departments. As a key part of the case, the government alleged the defendant had the intent to defraud the government.
Qui Tam Cases Involving Inpatient versus Outpatient Billing
A common scheme that whistleblowers identify when they choose to report billing fraud is: inpatient v. outpatient designation. In 2014, a qui tam case related to this type of billing fraud settled for $34 million. The complaint alleged that Community Health Systems Inc. (a large operator of acute care hospitals) billed government healthcare programs for more expensive inpatient services when it should have billed those services as outpatient or observation services. For a period of time, these types of qui tam cases were very successful.
Qui Tam Settlement For Medically Unnecessary Services
Another common type of healthcare billing fraud involves medically unnecessary services. In 2013, a whistleblower chose to report billing fraud against a Florida-based doctor. The whistleblower alleged the doctor billed Medicare for medically necessary services related to pathology labs. In other words, the doctor provided medical services to patients that they did not need. This case settled for $26.1 million. The whistleblower received an award for reporting the fraud to the government. Another type of medically necessary procedures is a case that settled against a California doctor for $2.7 million for performing necessary dermatology procedures.
Qui Tam Cases On Behalf of Private Insurance Companies
If an individual is seeking to report billing fraud by filing a qui tam case related to Medicare/Medicaid, then the whistleblower’s lawyer should also investigate if private insurance companies were defrauded by the same conduct. in sum, ff private insurance companies are also defrauded, the whistleblower might have a case under the California Insurance Fraud Prevention Act or CIFPA. Examples of cases brought under the CIFPA to report billing fraud can be instructive.
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