by Tim McInnis, Esq | Oct 14, 2022 | Qui Tam
Medicare Advantage Fraud occurs when healthcare insurers knowingly abuse the Medicare Part C program in order to make money unlawfully. Many American seniors are increasingly choosing Medicare Advantage Plans (MA Plans) over traditional Medicare Part A (hospital), Part B (physician) and Part D (prescription) healthcare coverage. Under the Medicare Advantage program, healthcare insurers get a monthly capitated fee from Medicare/CMS, plus a monthly premium from the members, and the insurers are supposed to provide superior healthcare and wellness services to the plan members at a lower cost to the members and U.S. tax payers.
The capitated amount Medicare pays the MA Plan sponsor (usually an insurance company) is based on a given member’s Medicare Risk Adjustment (MRA) score. In other words, the sicker the person is the more the insurance company receives from Medicare/CMS. This simple equation has motivated unscrupulous healthcare insurers with Medicare Advantage Plans to “game” or inflate their members’ MRAs with diagnoses that make members look sicker than they really are. It also incentivizes the MA Plan sponsors to “cherry pick” healthy members and/or provide substandard healthcare services to members in order to save money improperly.
If you work in this field you may have felt at times you would like to report Part C Medicare Advantage Fraud. It is likely you’ve seen an MA Plan sponsor implement one way audit programs which seek to add supposedly overlooked negative diagnoses to ramp up MRA scores, while not looking to uncover mistaken diagnoses that caused MRAs to be artificially high. Sometimes patient medical charts may even have been fabricated with outright bogus diagnoses. Maybe you are also aware of plan member recruitment tactics designed to bring in healthier members and keep out sicker ones. And it is possible you’ve seen systemic practices where a Medicare Advantage Plan sponsor tries to save money by failing to arrange for its members to receive the level of healthcare services they need. It’s conceivable you alerted a MA Plan sponsor about specific instances where any of these or similar practices have occurred and your concerns have fallen on deaf ears. It can be extremely disheartening. There is, however, an alternative way of trying to end MA Plan fraud.
If you have observed anyconduct you believe is improper and would like to report Medicare Advantage Fraud and help stop it, your best course of action may be to contact an experienced qui tam whistleblower attorney who can help guide you, assess your rights, contact the Government to report the fraud and even file a federal qui tam whistleblower lawsuit on your behalf. Many attorneys in this field will not charge you for a consultation and any communications you have with them will be privileged and confidential.
It is always best to begin this dialogue as soon as possible, especially if you still have access to evidence that can corroborate your allegations.
by Tim McInnis, Esq | Jul 9, 2022 | Uncategorized
You can support the Department of Justice’s National Nursing Home Initiative by filing a qui tam action under the federal False Claims Act for substandard nursing home care and fraudulent billing practices.
Since March 2020, DOJ has been focusing on long-term care providers, such as nursing homes, sub-acute rehabilitation centers and skilled nursing facilities (SNFs), who provide grossly substandard care to Medicare beneficiaries and/or bill for services that have not been rendered or were “upcoded,” including, rehabilitation treatment, like physical, occupational and speech therapy.
The government is looking for whistleblower cases involving gross abuse and neglect of Medicare patients and blatantly fraudulent billing practices. This includes inadequate care stemming from severely low staffing levels and the use of unlicensed and uncredentialed healthcare providers and aides. It also includes withholding necessary services and activities, including, psychiatric care. Failing to establish or follow plans of care and treatment. And not properly creating and maintaining medical records.
The government is also very focused on significant patient safety issues, like failing to follow
hygiene and infection control protocols. Dispensing unnecessary medications or failing to
provide necessary ones. Housing residents in unsafe or unacceptable living quarters. Failing to
provide adequate food and nourishment. Not attending to bed-ridden patients resulting in
pressure sores. Infrequently bathing and washing residents. Subjecting patients to verbal or
physical abuse. Physically restraining or sedating patients when not warranted. And
inadequately protecting patients’ safety and their personal belongings.
Overbilling and gaming the system for rehabilitation services is also a potential targeted area of
concern. The government is particularly interested in cases where the provider fails to establish
compliance programs and protocols. Turns a blind eye to patient and staff complaints and
warnings. And implements polices and practices that put profits far above quality of care.
Pervasive, long-standing and widespread misconduct involving substandard nursing home care
can result in a provider’s liability under the False Claims Act and a substantial reward to
whoever alerts the government to such conditions.
In the eyes of the law it is improper to file a claim for Medicare reimbursement for services to
nursing home residents knowing the quality of the care was grossly substandard. This is
because every provider’s Medicare claim for reimbursement carries with it an implication that all
material rules and regulations concerning patients’ wellbeing, safety and care have been
complied with. When they have not, then the claim for reimbursement might constitute a false
representation.
If that is what a court or jury finds, then the provider is potentially liable for three times the
amount of the improper payments it received, plus per claim fines of over $25,000, or even
criminal penalties. And, whoever blows the whistle on nursing home or elder care fraud is
potentially eligible for as much as 30% of any funds the government recovers.
The people in the best position to bring successful False Claims Act cases for nursing home
and elder care fraud are current employees. This is because it is important to have or be able to
amass patient-specific and detailed information and evidence corroborating allegations of
substandard nursing home care or Medicare billing fraud.
If you are aware of misconduct in a nursing home or other facility treating seniors and are
confident you have or can obtain strong proof of it, then you should immediately contact an
experienced qui tam whistleblower lawyer to learn about your rights and options.
by Tim McInnis, Esq | Jun 13, 2022 | False Claims Act
It’s no secret that private equity (PE) firms are increasingly acquiring healthcare and life science
businesses. And it is also no secret that when they do, these firms employ typical investment
strategies and practices that may make sense in some industries, but not those involving
patient treatment and care. After all, private equity (PE) firms usually seek to increase the debt
held by their portfolio companies, while trying to ramp up revenues and drastically cut costs.
In the healthcare and life science arenas this can lead to debt-laden balance sheets and
bankruptcies, unethical or unlawful sales and marketing schemes to boost revenues (including
by paying kickbacks) and massive cuts in essential staff and service levels. All of which can result
in underserving and improperly treating the patient population, many of whom are Medicare,
Medicaid and TRICARE beneficiaries. It can also lead to falsely billing government insurance
programs, resulting in False Claims Act violations and substantial rewards for whistleblowers.
Due to increasing fraud and abuse in the healthcare and life science fields, the U.S. Department
of Justice is taking a closer look at charging private equity (PE) firms with False Claims Act
“upstream” liability for the misconduct of their portfolio companies. This has resulted in a
number of large settlements in recent years.
Successfully pursuing False Claims Act cases against private equity (PE) firms requires two
things above and beyond the normal elements of proof in FCA cases. First, you need to show
that one or more members of the private equity (PE) firm had some role in causing the portfolio
company to submit false claims to a government program. This is usually done by showing their
control over, and involvement in, the day to day management and operation of the business.
For example, by controlling the board and through consulting and management service
contracts and the receipt of payments for such services. The second vital fact you need to
establish is that one or more members of the private equity (PE) firm knew about the
fraudulent and improper billing practices of the portfolio business. Often this can be proved by
showing that these investors turned a deliberate blind eye to such misconduct in their quest for
profits and/or that they failed to set up and monitor effective compliance programs.
If you believe a Private Equity (PE) firm might have upstream False Claims Act liability for the
misconduct of one or more of its portfolio companies (whether in the healthcare field or
otherwise), you should immediately contact an experienced qui tam whistleblower attorney.
Time is often of the essence, especially in larger organizations where many people know about the fraud and some may rush to preserve their rights since there is a first-to-file rule that generally bars subsequent whistleblowers from receiving a reward.
by Tim McInnis, Esq | May 21, 2022 | Uncategorized
False Claims Act Recoveries Top $5.6 Billion in 2021
In 2021, the United States government recovered more than $5.6 billion in False Claims Act
recoveries. A good deal of this money came from so-called “qui tam” law suits filed by private citizens.
Those with winning cases typically received between 15%-25% of the recovered amount, some even got
as much as 30%.
As has been true for a number of years, the lion’s share of the False Claims Act settlements and
judgments arose from healthcare fraud cases, mostly involving Medicare and Medicaid, and to a lesser
extent Tricare and Federal Employees Health Benefits (FEHB) program. We expect that trend to continue
for the foreseeable future, including in the Medicare Part C, Medicare Advantage Program, where “risk
factor gaming” has become more prevalent. Anti-Kickback Statute (AKS) and Stark Law violations for
improper referrals are also likely to loom larger. Of course, there will likely be no shortage of
unnecessary procedures, upcoding and billing for services not rendered cases.
With the trillions of dollars handed out during the COVID pandemic, one should also expect to
see any number of schemes where undeserving companies and organizations, as well as individuals, got
Stimulus money, PPP loans, CARES Act funds and Provider Relief money to which they were not entitled.
While this is not an exhaustive list of types of fraud cases heading our way, we do also want to
mention the government’s Cybersecurity Initiative, which aims to tackle the problem of hacking and
theft of government and government contractor data and the failure of those responsible for thwarting
these attacks. This is just one of the many types of procurement fraud the False Claims Act addresses,
along with more traditional defense industry and grant fraud.
If you think might have information about these and other types of potential qui tam False
Claims Act cases, you should immediately contact an experience whistleblower lawyer
by Tim McInnis, Esq | May 16, 2022 | False Claims Act
HOW TO REPORT CYBER SECURITY FALSE CLAIMS FRAUD
Did you know the Department of Justice introduced a new IT cyber security false claims initiative in 2021?
You might benefit from this IT cyber security false claims program if you report government contractors and grantees who didn’t protect sensitive electronic data from hackers. Reporting such activities in the right way could entitle you to a monetary reward.
What kinds of misconduct is covered by the government’s IT cyber security false claims initiative?
Broadly speaking, it falls into two categories. The first concerns government IT contractors, consultants and auditors who were supposed to provide protection against unauthorized access to government networks, hardware, devices, computer systems, software and electronic files and who knowingly provided substandard cyber security products or monitoring services and then submitted false claims to the government.
The other involves ordinary government contractors and grant recipients, such as those in the defense, aerospace, NASA, GSA and healthcare industries, who don’t meet acquisition and contracting regulations (like FARS, DFARS , NASA FARS, NIST, CMMC, FedRAMP, and HIPAA) requiring them to adequately monitor and provide a certain level of security for the sensitive government data they handle when performing under their contracts. Often the data at stake is unclassified controlled technical information (UCTI), sensitive but unclassified information (SBU), personally identifiable information (PII), personal health information (PHI), or other types of confidential information.
Who might be in a position to bring a cyber security case against an IT Contractor?
The ideal combination is someone who is knowledgeable about the IT products and services, the regulatory and contractual requirements, and the facts concerning the fraud, including, possible security breaches and the failure to accurately report them when submitting false claims to the government. For example, someone who works in a cyber security, compliance and controls unit of a government contractor may be in a good position to bring a successful case.
What do you need to do to benefit from the government’s cyber security fraud initiative?
You can bring a “qui tam” lawsuit under the False Claims Act against the contractor or grantee. If your case is successful and the defendant returns money to the government, you could be entitled to between 15% and 30% of the recovery. To do so, you must hire an attorney and file a lawsuit in federal court. If you even suspect some organization is submitting false claims to the government and think you may want to report it you should immediately contact an experienced and trusted whistleblower attorney to protect your rights.
