Medicare Fraud - Experienced Qui Tam Lawyers, Cost Report, PPS Fraud & DRG False Claims

Here at Nolan & Auerbach, our staff and healthcare fraud lawyers have had the privilege of helping our clients and others in cases ranging from coding false claims, DRG false claim, PPS false claims, outpatient PPS false claim, Stark law and kickback violations and other types of Medicare fraud. Medicare has been amended and expanded many times since it was enacted in 1965, and although efforts have been made to curtail fraud, we still have a long way to go. Medicare fraud has cost taxpayers billions over the last decade, and through the qui tam provisions of the False Claims Act, a significant portion has been returned to the U.S. Treasury. The purpose of the qui tam provisions of the False Claims Act is to encourage private individuals who are aware of fraud being perpetrated against the government to bring such information forward.

Today, government-run medical programs such as Medicare are ripe for plunder. The government pays money based upon a bare electronic submission indicating that particular services or supplies for a particular patient covered by Medicare have been rendered or furnished. There is no verification or due diligence. Medicare just pays. It is only when the Medicare fraud is large enough and/or egregious enough, that Medicare and the federal government will chase the ill-gotten funds.

The elimination of third-party payments ("assignment of benefits" directly to physicians and other providers as opposed to reimbursement of the beneficiary) will help, but there would still be a lot of cracks. Healthcare fraud simply is ripe for disclosure by whistleblowers, and it is important that the qui tam provisions of the False Claims Act continue to be available as incentive for honest-minded employees to come forward and expose fraud.

False Claims Act violations for Medicare fraud can be divided into categories, by the type of facility or healthcare provider involved. False claims Act violations that are made to providers such as hospitals, skilled nursing facilities, home health agencies, pharmacies, HMO's, physician groups, and so on include the following:

Payments made to providers other than hospitals/inpatient facilities are generally paid on the basis of a Medicare fee schedule. Potential False Claims Act violations include the following false claims:

Payments made to Medicare-funded managed care plans can result in violations of the False Claims Act, by practices such as:

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In addition to the false claims that are described above, two federal laws that criminalize conduct leading to over utilization, which can give rise to False Claims Act violations. The two laws which proscribe such conduct are the Stark laws and Anti-kickback laws:

The Stark law, 42 U.S.C. §1395nn, is also known as the Physician Self-Referral Law. If a physician (or immediate family member) has a direct or indirect financial relationship (ownership or compensation) with an entity that provides any of certain designated health services ("DHS"), the physician cannot refer patients to the entity for DHS and the entity cannot submit a claim to Medicare for such DHS unless the financial fits in a statutory or regulatory exception.

The Stark law was intended to prohibit physicians from profiting (actually or potentially) from their own referrals. The Stark law acts to sanction improper physician referrals, and does so by providing penalties for illegal referrals prospectively. Its effect is to prohibit relationships that have been demonstrated to encourage over-utilization. It is a strict liability statute, i.e. there is no need to show knowledge or intent.

The Medicare and Medicaid programs depend on physicians and other health care professionals to exercise independent judgment in the best interests of patients. Financial incentives tied to referrals have a tendency to corrupt the health care delivery system in ways that harm the federal programs and their beneficiaries. Corruption of medical decision-making can result when a physician refers a patient to a provider on the basis of the physician's financial self-interest instead of the patient's best interests.

Overpaid medical directorships, interest free loans/forgiveness of debts, illegal recruitment arrangements and improper discounts, may represent financial windfalls to physicians resulting in hospital referrals in violation of the "Stark Law" statute. Examples also include sham contracts which provide for "backdoor" "sweet deals" between hospitals (which afford to physicians benefits like, office space, renovations, equipment, furniture, housekeeping services, office supplies, copy and fax machines, telephone and utility as well as transcription services) and referring physicians, which amount to benefits to physicians for free or less than fair market value.

A violation of the Stark law can be the basis for False Claims Act liability.

Anti-Kickback Law

The federal Anti-kickback statute, 42 U.S.C. § 1320a-7b(b), arose out of congressional concern that payoffs to those who can influence healthcare decisions will result in goods and services being provided that are medically unnecessary, of poor quality, or even harmful to a vulnerable patient population. To protect the integrity of the program from these difficult to detect harms, Congress enacted a per se prohibition against the payment of kickbacks in any form, regardless of whether the particular kickback gave rise to over utilization or poor quality of care.

The Anti-kickback statute prohibits any person or entity from making or accepting payment to induce or reward any person for referring, recommending or arranging for federally-funded medical services, including services provided under the Medicare, Medicaid and TRICARE programs.

A violation of the Anti-kickback statute can give rise to False Claims Act liability.

Federal Medicare fraud, ranging from DME false claims, DRG false claims, coding fraud, Stark law and anti-kickback violation, clinical trial fraud, and PPS fraud are only a few of the types of health care fraud cases that we handle. We also can provide you with experienced representation with medical device fraud and pharmaceutical fraud, both which include clinical trial fraud and cMPG fraud.

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