Health Care Fraud Whistleblower Actions

Health care fraud is a major factor behind skyrocketing health costs. Improper claims cost the government tens of millions of dollars every year. Despite government efforts to crack down on health care fraud, including Medicare and Medicaid fraud, the sheer volume of health care claims makes it extremely difficult to catch entities committing fraud.

The individuals who are in the best position to identify fraud are the employees who work there. To encourage individuals to step forward, the government rewards health care fraud whistleblowers by giving them a percentage of any funds recovered. At Cross Law Firm, S.C., we protect whistleblowers by helping them to properly file sealed claims in federal court throughout the country.

Our firm is a national leader in qui tam whistleblowing actions under the False Claims Act. We know what we are doing, and our lawyers know how to protect whistleblowers. We brought and obtained the first recovery in the country for nationwide hospice care fraud and we obtained the first recovery under the False Claims Act based on violations of Medicare Part D and the Controlled Substances Act. We also obtained an award for our whistleblower in one of the rare David-Bacon qui tam cases.

Types Of Health Care Fraud

Health care fraud takes many forms and is not always easy to decipher. Some forms of fraud include:

Billing and coding fraud — Billing fraud is the most common form of health care fraud. The Medicaid and Medicare systems have been bilked out of millions by facilities billing for services that were never given or not needed. This is done either by padding existing claims with extra services or inventing claims using the identity of a real patient. Billing fraud can also include upcoding, which uses medical billing codes to charge for more expensive or complicated services than were actually needed.

Unbundling — Providers also commit fraud when they unbundle services that are usually provided together at a discounted rate. By unbundling these services and spreading out the charges over time, health care providers are able to obtain greater compensation for the same services.

Kickbacks — Kickbacks are any form of compensation given in exchange for using a particular drug or medical product. Kickbacks may be made in cash, through Medicaid or Medicare or by providing gifts, discounted products or patient referrals. If there is an intent to influence a physician or health care provider, it violates the federal anti-kickback statute. Pay-to-play kickback schemes are prevalent in health care fraud.

Co-Pay Inflation — Patients become the victims of health care fraud when they are billed more than their actual co-pay for health care services.

Lack of Medical Necessity Medical providers can run up charges by conducting expensive tests or perform unnecessary procedures on patients who do not need them.

Medicare Part D Fraud — Medicare Part D covers prescription drugs and is highly susceptible to fraud. Sometimes pharmacies charge for brand name drugs when providing generic drugs, fill prescriptions from doctors that either do not exist or who are not Medicare eligible, or vendors make misrepresentations when bidding with the Centers for Medicare & Medicaid Services (CMS) for a drug.

Falsification of Medical Records — To support a medically unnecessary claim for payment, providers may falsify patient records, creating a false claim.

Our Track Record Of Success With Health Care Fraud Cases

Our firm's founding attorney, Nola Hitchcock Cross, has a strong record of success handling false claims cases. She filed the PharMerica case leading to the recovery of $31.5 million (including DEA penalties) for allegedly falsely billing the government and failing to track dangerous Schedule II narcotics they were dispensing nationally. Read her client testimonials.

She filed the Forest Labs case leading to the recovery of $38 million for allegedly pursuing a "pay-to-play" scheme to compensate doctors for writing prescriptions under the guise of a drug speakers program. Details of this are also available on her testimonials page.

Get Involved. Find Out If You have A Case

Most people who pursue a health care fraud whistleblower case do so to correct a wrong. When health care costs skyrocket, we all suffer. Pursuing a False Claims Act case against a company can stop the abuse and deter other companies from engaging in such abuse. If you are concerned that your employer may be committing health care fraud, schedule a free consultation with an attorney at our firm. Call our law office at 414-224-0000 or send us an email online.