Medicare Billing Fraud

3. Are there any hidden landmines that I need to watch out for in these kinds of cases?

The two most important hidden landmines we look for in Medicare Billing Fraud cases are: (a) anything about potential HHS/CMS regulations and policies that are inconsistent with our theory of the case; and (b) whether the HHS/CMS is going to disagree that the provider should not have gotten paid in whole or in part.

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4. How is the amount of the “damages” calculated in healthcare cases?

It really depends on the nature of the fraud. Sometimes it is the entire amount of the reimbursement; sometimes it is the net amount after taking into consideration the value of the goods or services actually provided; and sometimes the amount might even be zero. There are also times with the amount of potential damages is reduced by a healthcare provider’s “ability to pay” and whether there is a risk that a needed provider is going to be put out of business. This is a constantly evolving legal issue that has tremendous impact on relators because they only receive a percentage of what a defendant actually pays the Government.

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