New whistleblower reward laws are expanding the ability of Medicaid fraud whistleblowers to collect large economic rewards to encourage health care providers to blow the whistle on health care fraud including illegal Medicaid retention of overpayments, Medicaid illegal kickback scams, Medicaid upcoding, Medicaid double billing, Medicaid false coding, Medicaid unbundling, and other fraudulent Medicaid billing practices. 

If you are a health care professional that is aware of Medicaid fraud including retention of Medicaid overpayments, please feel free to contact Medicaid Retention Overpayment Whistleblower Lawyer and Medicaid Billing Fraud Whistleblower Lawyer Jason Coomer via e-mail message or our submission form about a potential Medical illegal overpayment retention lawsuit, Medicaid upcoding whistleblower lawsuit, Medicaid illegal kickback whistleblower lawsuit, Medicaid bill padding whistleblower lawsuit, Medicaid double billing lawsuit, or other Medicaid billing fraud qui tam lawsuit. 

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The 2009 Fraud Enforcement and Recovery Act (FERA) and many new state Medicaid fraud whistleblower laws are expanding Medicaid fraud whistleblower recovery laws and other Bounty Reward Actions to increase potential rewards for relators, expand potential liability for Medicaid fraud criminals and violators, and to increase protections to Medicaid fraud whistleblowers.  These new laws are designed to help the Federal government and state governments identify, recoup, and crack down on Medicaid fraud, Medicare fraud, and other forms of health care fraud which is estimated to be over $100 Billion per year. 

With Medicare and Medicaid costs continuing to grow and many government budgets being tight, it is essential that health care providers with knowledge of Medicaid fraud, Medicare fraud, or other health care fraud to step up and expose the health care fraud and systematic Medicaid fraud that is the fasting growing and most lucrative crimes in the United States.    

In developing and strengthening Medicaid fraud whistleblower laws, governments are setting up increased whistleblower protections and economic incentives to encourage health care providers to blow the whistle on traditional qui tam health care fraud causes of action and are expanding the causes of action to include rewards to whistleblowers that expose retention of Medicaid overpayments.  Many of these False Claims Act statutes and Medicaid Fraud statutes have also been expanded to include government contractor false claims, government grantee false claims, and other recipients of government money that submit false claims to obtain this money.

For more information on potential Medicaid fraud whistleblower recoveries and Medicaid fraud whistleblower protections, it is important to contact a Medicaid retention of overpayment fraud lawyer, Medicaid whistleblower illegal kickback lawyer, Medicaid whistleblower upcoding lawyer, Medicaid whistleblower double billing lawyer, Medicaid whistleblower false coding lawyer, Medicaid whistleblower unbundling lawyer, or other health care fraud whistleblower lawyer to maximize your ability to obtain a substantial whistleblower recovery and understand whistleblower protections from potential retaliation.

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Medicaid is a federal/state cost-sharing program that provides health care to people who are unable to pay for such care.  The Medicaid Program is jointly funded by state and federal governments, but is managed by the states.  Medicaid is the largest source of funding for medical and health-related services for people with limited income in the United States and the Medicaid program has been increasing.  The fastest growing aspect of Medicaid is nursing home coverage and this is expected to continue as the Baby Boomer generation begins to reach nursing home age. 

Unlike Medicare, which is solely a federal program, Medicaid is a joint federal-state program. Each state operates its own Medicaid system.  Each state's Medicaid Program must conform to federal guidelines in order for the state to receive matching funds and grants.  For many states Medicaid has become a major budget issue as on average the state's matching costs of the Medicaid program is about 16.8% of state general funds. According to CMS, the Medicaid program provided health care services to more than 46.0 million people in 2001. In 2008, Medicaid provided health coverage and services to approximately 49 million low-income children, pregnant women, elderly persons, and disabled individuals. Federal Medicaid outlays were estimated to be $204 billion in 2008.  Medicaid payments currently assist nearly 60 percent of all nursing home residents and about 37 percent of all childbirths in the United States. The Federal Government pays on average 57 percent of Medicaid expenses.

Medicaid fraud is a violation of federal law and several new state Medicaid fraud laws.  Health care providers that are convicted of Medicaid fraud can be fined, incarcerated, and lose their status as Medicaid providers.  To prevent Medicaid fraud, several states including Texas, California, Florida, Hawaii, Massachusetts, Nevada, Tennessee, Wisconsin, New Jersey, Georgia, Michigan, Illinois, Louisiana, Delaware, Indiana, Minnesota, Montana, New Mexico, Oklahoma, North Carolina, and Virginia have enacted state Medicaid fraud whistleblower recovery laws.  These Medicaid fraud whistleblower laws are based on the Federal False Claims Act and many acts of large scale systematic Medicaid fraud will entail aspects of several different laws.    

There are many types of Medicaid fraud that may be the basis for Medicaid fraud whistleblower recovery lawsuits and other qui tam claims including:

• billing Medicaid for X-rays, blood tests and other procedures that were never performed

• falsifying a patient’s diagnosis to justify unnecessary tests;

• giving a patient a generic drug and billing for the name-brand version of the medication;

• giving a recipient a motorized scooter and billing for an electric wheelchair, which can cost three times more;

• billing Medicaid for care not given;

• billing Medicaid for patients who have died or who are no longer eligible for Medicaid;

• billing Medicaid for care given to patients who have transferred to another facility;

• transporting Medicaid patients by ambulance when it is not medically necessary;

• requiring vendors to “kick back” part of the money they receive for rendering services to Medicaid patients (kickbacks may also include vacations, merchandise, etc.);

• billing patients for services already paid for by Medicaid;

• billing Medicaid for phantom patients;

• double billing Medicaid for services;

• upcoding services for increased Medicaid payments.

Upcoding occurs when a medical service provider intentionally and fraudulently upcodes services to obtain a higher reimbursement than one that is entitled to for the service that was actually provided.  In both the Medicare and Medicaid systems a set of billing codes is used by healthcare providers to bill for services. These codes are known as the Healthcare Common Procedure Coding System (HCPCS). A service provider that intentionally uses a higher paying code to fraudulently reflect that a more expensive procedure or device was involved in the patient’s treatment than actually was used or was necessary.  A pattern of intentional upcoding treatment can result in large profits for the healthcare provider, but also cost taxpayers millions of dollars.

Upcoding fraud is typically hard to catch without the help of persons with inside information because that Healthcare Common Procedure Coding System (HCPCS) codes are billed electronically and can easily slip through the system.  Therefore unless the upcoding is caught through a random audit (approximately 2% of the claims per year are audited), it is up to insiders, informants, heroes, and health care professionals to catch fraudulent upcoding.

Another type of coding fraud is “unbundling”, where bundled related procedures or composite lab tests are run together, but billed separately by the lab or healthcare provider to obtain more compensation.  These types of billing fraud also allow healthcare providers and labs to make higher profits by bilking Medicare, Medicaid, and taxpayers out of millions of dollars.  These unbundling fraud schemes are also hard to detect without someone that is familiar with the codes and billing.

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To prevent Medicaid fraud, Texas has enacted the Texas False Claims Act and Medicaid Fraud Prevention Act.  In Texas, the Medicaid program is administered by the Texas Health and Human Services Commission. More than 3.7 million Texans are eligible for Medicaid, and there are more than 57,000 active Medicaid providers. A provider can be any person, group of people, or health care facility that supplies medical services to Medicaid recipients. Providers include doctors, medical equipment companies, podiatrists, dentists, licensed professional counselors, hospitals, adult day care centers, nursing homes, clinics, pharmacies, ambulance companies, case management centers and others.

The Texas Medicaid program costs about $30 Billion each year and is expected to continue to increase in the future.  Of this cost, it is estimated that Medicaid fraud costs are between Two Billion Dollars ($2,000,000,000.00) to Four Billion Dollars ($4,000,000,000.00) each year. 

For more information on Texas Medicaid Fraud Whistleblower Recovery Law, please feel free to go to the following webpage: Texas False Claims Act Lawsuit, Texas Medicaid Fraud Whistleblower Recovery Lawsuit, Texas Medicaid False Billing Whistleblower Award Lawsuit, Texas Medicaid Double Billing Fraud Lawsuit, Texas Medicaid Fraud False Billing Lawsuit, Texas Unnecessary Medical Treatment Relator Lawsuit, and Texas Medicaid Fraud Whistleblower Lawsuit Information 

  Qui Tam Whistleblower Plaintiffs have received over $1 Billion in Awards of the over $12 Billion in Recoveries for Exposing Fraud Against the United States Government (Qui Tam Plaintiff Whistleblower Claims)

Medicaid, Tricare, Veterans Administration, Hospice, and Medicare Whistleblowers that provide original source information of schemes to fraudulently take money from our United States government including upcoding, double billing, bill padding, unbundling, and charging for services never provided may recover a portion of the proceeds recovered on the government's behalf.  Since 1986, relators have recovered over $1 billion for helping expose fraud against the United States government. 

Below is an excerpt from the False Claims Act explaining what types of awards qui tam whistleblowers may recover for being the "original source" of information that is used to successfully expose fraud against Medicaid, Tricare, Veterans Administration, Hospice, Medicare, or another subdivision of the United States Government and recover money from the parties committing the fraud. 

(d) AWARD TO QUI TAM PLAINTIFF

(1) If the Government proceeds with an action brought by a person under subsection (b), such person shall, subject to the second sentence of this paragraph, receive at least 15 percent but not more than 25 percent of the proceeds of the action or settlement of the claim, depending upon the extent to which the person substantially contributed to the prosecution of the action. Where the action is one which the court finds to be based primarily on disclosures of specific information (other than information provided by the person bringing the action) relating to allegations or transactions in a criminal, civil, or administrative hearing, in a congressional, administrative, or Government [General] Accounting Office report, hearing, audit, or investigation, or from the news media, the court may award such sums as it considers appropriate, but in no case more than 10 percent of the proceeds, taking into account the significance of the information and the role of the person bringing the action in advancing the case to litigation. Any payment to a person under the first or second sentence of this paragraph shall be made from the proceeds. Any such person shall also receive an amount for reasonable expenses which the court finds to have been necessarily incurred, plus reasonable attorneys’ fees and costs. All such expenses, fees, and costs shall be awarded against the defendant.

(2) If the Government does not proceed with an action under this section, the person bringing the action or settling the claim shall receive an amount which the court decides is reasonable for collecting the civil penalty and damages. The amount shall be not less than 25 percent and not more than 30 percent of the proceeds of the action or settlement and shall be paid out of such proceeds. Such person shall also receive an amount for reasonable expenses which the court finds to have been necessarily incurred, plus reasonable attorneys’ fees and costs. All such expenses, fees, and costs shall be awarded against the defendant.

Since amendments were made to the Federal False Claims Act in 1986, citizens that have filed suits on behalf of the federal government against government contractors that have participated in defrauding the government have regained over $12 Billion for taxpayers as well as have collected over $1 Billion in qui tam whistleblower awards. 

Medicare and Healthcare Fraud Law Suits (Qui Tam Claims)

HEALTH CARE FRAUD CASE NETS RECOVERY OF $1.7 BILLION

HCA Inc. (formerly known as Columbia/HCA and HCA - The Healthcare Company) and HCA subsidiaries agreed to pay the United States over $1.7 Billion including $631 million in 2003 for civil penalties and damages arising from false claims the government alleged it submitted to Medicare and other federal health programs. In 2000, HCA subsidiaries pled guilty to substantial criminal conduct and paid more than $840 million in criminal fines, civil restitution and penalties.  HCA will pay an additional $250 million to resolve overpayment claims arising from certain of its cost reporting practices.  In total, the government will have recovered $1.7 billion from HCA.

This Qui Tam settlement resolved fraud allegations against HCA and HCA hospitals in nine False Claims Act qui tam or whistleblower lawsuits pending in federal court in the District of Columbia. Under the federal False Claims Act, private individuals may file suit on behalf of the United States and, if the case is successful, may recover a share of the proceeds for their efforts. Under the HCA settlement, the whistleblowers will receive a combined share of $151,591,500.00.

http://www.usdoj.gov/opa/pr/2003/June/03_civ_386.htm

Whistleblower Protection Under the Federal False Claims Act

The Federal False Claims Act has strong whistleblower protection provisions that protect Qui Tam False Claims Act whistleblowers from retaliatory actions by violators of the Federal False Claims Act.

Under Section 3730(h) of the False Claims Act, "[a]ny employee who is discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of employment by his or her employer because of lawful acts done by the employee on behalf of the employee or others in furtherance of an action under this section, including investigation for, initiation of, testimony for, or assistance in an action filed or to be filed under this section, shall be entitled to all relief necessary to make the employee whole. Such relief shall include reinstatement with the same seniority status such employee would have had but for the discrimination, 2 times the amount of back pay, interest on the back pay, and compensation for any special damages sustained as a result of the discrimination, including litigation costs and reasonable attorneys' fees. An employee may bring an action in the appropriate district court of the United States for the relief provided in this subsection."

For more information on Whistleblower Protection Under the Federal False Claims Act or other Federal Whistleblower Protections, please go to the following Whistleblower Protection Webpage.

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Government Contractor Fraud Qui Tam Whistleblower Lawsuit Information (False Claims Act Whistleblower Qui Tam Action Information)

For more information on Medicare Fraud, Tricare Fraud, Medicaid Fraud, Defense Contractor Fraud, Off Label Fraud, Road Construction Fraud, and other types of False Claims Act Whistleblower Claims, please go to the Qui Tam, Whistleblower, and Federal Federal False Claims Act Information Center.

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