Health Care Fraud | Whistleblower Claims

Understanding Health Care Fraud & The False Claims Act

If you have witnessed fraudulent billing, kickbacks, or misconduct in the healthcare industry, you may have grounds to file a whistleblower claim under the False Claims Act. The Lyon Firm represents individuals nationwide in complex qui tam litigation, protecting whistleblowers from retaliation and fighting for the compensation they deserve. Contact The Lyon Firm today for a confidential consultation to discuss your potential case.

The False Claims Act and Qui Tam Provisions

The False Claims Act (FCA) is a federal law originally enacted during the Civil War to combat fraud by government contractors. Today, it is the primary mechanism for holding healthcare providers accountable for submitting false or fraudulent claims to Medicare, Medicaid, TRICARE, and other government health programs.

The FCA’s qui tam provisions allow private individuals, known as relators, to file lawsuits on behalf of the government. If the case is successful, the whistleblower may receive between 15 and 30 percent of the recovery. The Lyon Firm guides whistleblowers through this process, ensuring their claims are properly documented and filed under seal.

the help of whistleblowers in the healthcare industry, the U.S. government is able to recover billions of dollars each year from companies and individuals defrauding the government, and improperly pocketing federal agency funds.

The Medicare and Medicaid programs are often the target of unscrupulous companies and management because of the size of the programs and the vast amount of funds available for the industry.

Drug companies, hospitals, health professionals and other health care workers have taken advantage of American tax dollars, but with the help of whistleblowers around the country, much of this money is returned to the government and restored to its proper place. Those responsible for recovering federal funds are eligible for substantial financial compensation.

Of the $4.7 billion False Claims funds recovered in 2016, $2.5 billion came from the health care industry. This is the seventh consecutive year health care fraud recoveries have exceeded $2 billion. The largest recoveries this past year ($1.2 billion) came from the drug making and medical device industry.

Whistleblowers play a critical role in exposing fraudulent billing, kickbacks, and other misconduct. The Lyon Firm helps whistleblowers step forward, file qui tam claims correctly, and pursue the compensation they deserve.

Joe Lyon is a highly-rated Health Care Fraud lawyer representing plaintiffs nationwide in a wide variety of workplace fraud claims.

Medicaid & Medicare Fraud Claims

Health Care Fraud claims have increased in recent years, and money recovered in the last 7 years represents over 50 percent of all health care fraud money recovered. Because individual whistleblowers have been courageous enough to tip the authorities and risk their jobs, government fund recoveries in 2016 totaled over $1.2 billion.

The majority of the money recovered in the last few years came from pharmaceutical and medical device companies. The most common institutions to defraud the U.S. government of Medicaid and Medicare funds include:

• Hospitals
• Medical Laboratories
• Pharmaceutical companies
• Medical device companies
• Nursing homes
• Individual physicians
• Healthcare affiliates
• Electronic Health Record Vendors

Common Types of Healthcare Fraud

Healthcare qui tam lawsuits target a wide range of fraudulent practices. Some of the most common include:

Upcoding and Unnecessary Services

Providers may submit claims for more expensive procedures than those actually performed or bill for services that were medically unnecessary.

Kickbacks and Stark Law Violations

The Anti-Kickback Statute and the Stark Law prohibit healthcare providers from paying or receiving financial incentives for referrals. Qui tam lawsuits often allege that hospitals, labs, or pharmaceutical companies violated these laws.

Pharmaceutical and Device Fraud

Drug and device manufacturers have faced lawsuits for promoting off-label uses, misrepresenting safety data, or offering unlawful inducements to prescribers.

Cost Reporting Fraud

Hospitals and nursing facilities may misrepresent costs on reports submitted to Medicare or Medicaid to inflate reimbursements.

Billing for Phantom Patients or Services

Some providers bill for patients who never received treatment or for services never rendered, leading to clear FCA violations.

Individuals in the healthcare industry are also frequent targets in Medicare and Medicaid fraud claims. Physicians have been fined for overbilling or improperly billing Medicare and Medicaid for unnecessary medical procedures.

If you have knowledge of individuals or corporations defrauding the government, contact a health care fraud lawyer and you may be entitled to a substantial reward.

Whistleblowers across the country have helped recover millions of dollars in Medicare, Medicaid and other healthcare fraud claims. Those who are courageous enough to come forward with valuable information regarding fraud can be rewarded, and are encouraged to contact an experienced Medicare Fraud lawyer.

Federal Medicare and Medicaid funds have been pilfered by unscrupulous doctors, drug companies and healthcare facilities, costing the American taxpayers and damaging important institutions. Whistleblowers can receive a percentage of the recovered funds, granting that information they provide leads to the recovery of lost funds.

Companies and individuals continue to defraud the U.S. government, and only through Qui Tam Lawsuits can Medicare and Medicaid programs limit the unethical practice of healthcare fraud. Individual prescribing physicians and drug companies are the most common defendants in the healthcare industry in fraud claims.

Doctors can be fined, prosecuted and have their license revoked for improperly billing Medicare and Medicaid for unnecessary drugs or unnecessary medical procedures.

Following fraudulent activity in hospitals and medical centers, whistleblowers may contact a Medicare fraud lawyer to investigate the matter, protect their job and interests and be eligible for a settlement and reward. The majority of the money recovered in whistleblower lawsuits comes from pharmaceutical and medical device companies, as well as hospital management and doctors.

The Legal Process for Qui Tam Cases

Healthcare qui tam lawsuits follow a structured process:

1. Filing the Complaint Under Seal – The relator files a lawsuit under seal in federal court. The Lyon Firm ensures the complaint is properly filed and documented.
2. Government Investigation – The DOJ investigates the allegations, often with help from the OIG and other agencies.
3. Government Intervention Decision – The government decides whether to intervene. If it does, the case often gains momentum.
4. Litigation and Resolution – Cases may resolve through settlement or trial, with damages and penalties determined by the court.

A federal judge recently unsealed a whistleblower lawsuit filed against ProScan, an MRI-reading company. The complaint alleges that physician assistants improperly read hundreds of MRIs each day and wrongly diagnosed patients. This means unlicensed readers were taking the role of doctors, and MRIs were not properly reviewed by a qualified physician.

ProScan was contacted by the DOJ with a request for information related to the whistleblower claims and government investigation. The False Claims Act Qui Tam lawsuit was filed by a former ProScan radiology assistant.

The plaintiff accused ProScan of allegedly submitting thousands of fraudulent claims for Medicare and Medicaid reimbursement for MRIs, costing the government hundreds of millions of dollars.

Health Care Fraud & Qui Tam Claims

• Both GlaxoSmithKline and Bayer allegedly sold medication to an HMO at discounted prices, and concealed the discount to avoid a legal obligation to pay millions of dollars in additional rebates to the Medicaid program. The whistleblowing individual was awarded $34 million.
• Eli Lilly paid more than $1.4 billion in fines, penalties and damages after a whistleblower alleged that the company defrauded Medicare, Medicaid, and other government-funded health care programs in connection with a marketing scheme for Zyprexa.
• Damon Clinical Laboratories, Inc. allegedly illegally billed the Medicare and Medicaid program by ordering unnecessary lab tests. The government recovered more than $83 million from Damon Lab, and one of the whistleblowers received $9 million.
• Blue Cross-Blue Shield paid $2.75 million after the company allegedly falsified Medicare reports and inflated the number of processed claims. The plaintiff was a former employee and was awarded over a half of a million dollars. In a separate but similar case, Blue Cross-Blue Shield paid $27.6 million for allegedly submitting false documentation and fraudulent billing. A former auditor tipped the government, and received a multi-million dollar reward.
• Novartis Pharmaceuticals Corp. paid $390 million based on claims that the company allegedly gave kickbacks to specialty pharmacies in return for recommending specific drugs to kidney transplant recipients.
• Tenet Healthcare, a major hospital chain in the U.S., paid $244 million to resolve civil allegations that its hospitals allegedly engaged in a scheme to defraud the United States by paying kickbacks in return for patient referrals.
• Millennium Health paid $260 million to settle allegations that it billed Medicare, Medicaid, and other federal health care programs for excessive urine, drug and genetic testing, and also distributed free items so physicians would refer expensive lab tests to Millennium.

Healthcare Kickback Schemes

Medical specialists in fields like labor and delivery, pain management, cardiology and other practice areas regularly refer patients for tests, procedures, surgeries and other services, making the an attractive target for illegal kickback schemes.

Referring fellow physicians or other health care providers or pushing certain medications can violate specific kickback statutes and can lead to fraud allegations.

Whistleblowers in recent years have come forward and reported illegal healthcare kickback activities, and have been awarded for the money they recovered for government programs like Medicare and Medicaid.

It is illegal for doctors and specialists to take money from providers and pharmaceutical reps and medical device suppliers in return for the referral of Medicare and Medicaid patients. In turn, it is illegal to pay others for Medicare and Medicaid patient referrals.

Any healthcare kickback scheme can be reported by whistleblowers and those who come forward can be awarded in kickback lawsuits. Kickbacks in health care are highly discouraged, as they are likely to lead to:

• Increased government spending
• Overutilization
• corruption of medical decision-making
• Patient
• Unfair competition

Anti-Kickback Statute

The Anti-Kickback Statute (AKS) is a criminal law that prohibits the payment of “remuneration” to induce or reward patient referrals or the generation of business involving any product or service payable by federal health care programs—drugs, medical supplies, or health care services for Medicare or Medicaid patients.

Remuneration in kickback schemes can include anything of value, including money, free rent, hotel stays and meals, and excessive compensation for medical consultancies. Regarding federal health care programs, paying for referrals is a crime.

Criminal penalties and administrative sanctions for violating the anti-kickback statute may include fines, jail terms, and the loss of a medical license. Physicians who pay or accept kickbacks may face penalties of up to $50,000 per kickback instance plus 3X the amount of the remuneration.

Whistleblowers can be awarded up to 30 percent of the recovered amount. The Department of Justice obtained more than $3 billion in settlements and judgments from civil whistleblower cases involving false claims against the government in 2019, many of which involved illegal health care kickback schemes.

Other important federal fraud and abuse laws that apply to physicians are the False Claims Act (FCA), the Physician Self-Referral Law (Stark law), the Exclusion Authorities, and the Civil Monetary Penalties Law (CMPL). The kickback statute applies to all sources of referrals. Even waiving copays can demonstrate an illegal act in some cases for Medicare and Medicaid patients. It is legal, however, to provide free or discounted services to uninsured people.

According to the government, anti-kickback laws are concerned with preventing financial considerations from warping physicians’ medical decisions. Some health care kickback lawsuits have been filed when hospitals pay doctors enormous sums in salaries and incentives, often expecting hospital referrals.

Hospitals may disguise physicians’ salaries, or even base their pay on how much business they generate. Doctors generate business each time they order a procedure or test, or decide that a patient needs to be admitted overnight or see a specialist. The average internist can generate up to $3 million in hospital revenue each year.

Medical Device Kickbacks

Medical device and drug companies have found ways to sidestep bribery and anti-kickback laws in the past, though in light of the opioid crisis, the Justice Department has been trying to crack down on practicing doctors working almost directly for pharmaceutical companies.

In a recent whistleblower settlement, ResMed Corp., a medical equipment manufacturer, agreed to pay more than $37 million to resolve alleged False Claims Act violations for paying kickbacks to suppliers, sleep apnea labs and other health care providers.

The settlement resolves allegations that ResMed provided companies with interest-free loans, free services which enabled them to order resupplies for their patients with sleep apnea, and free equipment to non-sleep specialist physicians.

When companies give free equipment to doctors to generate business and increasing profits, federal health insurance programs pay the bills. The plaintiff’s attorney made the following statement: “Medical decisions should be based on what is in the best interest of the patient and not based on financial incentives and related schemes.”

The agreement resolves five whistleblower lawsuits under the qui tam provisions of the False Claims Act.  The False Claims Act allows citizens with knowledge of healthcare fraud against the government to bring a lawsuit on behalf of the U.S. government and to share in the recovery.  The ResMed whistleblowers will receive over $6 million in the settlement.

Pharmaceutical Kickbacks

Healthcare profiteering is a problem in the big pharma side of the industry as well. Teva Pharmaceuticals agreed to pay $54 million to settle a whistleblower lawsuit claiming it paid doctors to prescribe Copaxone and Azilect. Former Teva sales reps sued the company in 2013, alleging the company set up a program to pay doctors to prescribe the drugs through large speakers’ fees.

Novartis has been facing numerous healthcare fraud lawsuits, and whistleblowers have identified illegal kickbacks to at least 20 pharmacies for selling the medication Myofortic. Pharmacies who switched kidney transplant patients from a competitor’s medication to Myfortic were allegedly compensated in the form of rebates and discounts.

The kickback scheme resulted in huge growth in Myfortic sales. Another whistleblower lawsuit alleges that Novartis handed out illegal kickbacks to physicians in exchange for prescribing the medications Lotrel, Valturna and Starlix.

The Swiss corporation allegedly enticed, bribed and rewarded doctors in a kickback scheme that lasted years. This led to Medicare and Medicaid reimbursing Novartis with millions of dollars.

Healthcare Whistleblower Settlements

The Department of Justice recently reported that it had recovered $19.3 billion in healthcare fraud claims from 2009 to the end of 2016, representing 57 percent of all health care fraud money recovered in the last 30 years. Healthcare fraud whistleblowers that lead to the recovery were well-compensated, and the money recovered restored assets to important federally funded programs like Medicare and Medicaid.

As the government tries to prevent health care fraud and billions in losses, the False Claims Act enables employees and citizens to expose fraud from within companies, protect themselves from retaliation, and makes them eligible for large rewards that may reach into the millions. Healthcare fraud whistleblowers can expect to receive between 15 and 30 percent of the overall recovery of a successful fraud (qui tam) lawsuit.

Why Hire The Lyon Firm?

Whistleblowers considering a qui tam lawsuit need experienced legal guidance. The Lyon Firm has represented clients in False Claims Act litigation nationwide, with a track record of holding healthcare providers accountable for fraudulent billing, kickbacks, and deceptive practices.

The firm offers confidential consultations, builds strong evidence-backed cases, and advocates aggressively for whistleblowers’ rights and rewards. By working with The Lyon Firm, clients gain a trusted advocate who will pursue justice, protect them from retaliation, and fight for fair compensation.