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 Author | Feb 24, 2016 | Customs Fraud, False Claims Act, Qui Tam
On Monday, February 22nd, 2016, the Department of Justice announced that four Pennsylvania-based companies and two individuals had agreed to pay $3 million to settle a False Claims Act Suit involving customs duties. The companies—Ameri-Source International Inc., Ameri-Source Specialty Products Inc., Ameri-Source Holdings Inc., and SMC Machining LLC—and the individuals—Ajay Goel and Thomas Diener – were accused with evading customs duties on imports of small-diameter graphite electrodes from China, which are used as fuel in electric arc and ladle furnaces. The U.S. government alleged that the companies had deliberately misclassified the electrodes as a larger size from December 2009 to March 2012; because larger size electrodes are not subject to antidumping duties, the misclassification allowed the companies to evade the necessary customs duties for smaller size electrodes. The allegations resolved by the settlement were originally brought by whistleblower Graphite Electrode Sales Inc. under the qui tam provisions of the False Claims Act. Graphite Electrode Sales Inc., a competitor of the named defendants, will receive approximately $480,000 as its share of the settlement.
by Author | Feb 2, 2015 | False Claims Act, Qui Tam
What happens when Whistleblowers Violate The Seal in qui tam cases? Recently, two relators in Georgia found out the hard way: they were lucky to get away with paying a penalty of only $1.61 million for their indiscretions.
Frustrated by the Government’s slow investigation of their allegations, the relators contacted Fox News and shared confidential information with the news organization. Once the defendant found out that the relators had broken the seal order of the court, it sought to get the relators dismissed completely from the case. (Such results are rare but not unheard of in False Claims Act cases.). That would have cost them the entire $43,161,500 they were slated to receive for pursuing a successful non-intervention case against Wells Fargo for allegedly defrauding the Veterans’ Administration by overcharging on closing costs for residential mortgages for veterans.
The lesson here is a simple one: do not discuss your case with anyone other than your attorney because loose lips can cost you $ millions.
For more on this case see: United States ex rel. Bibby v. Wells Fargo Bank, N.A., 2015 U.S. Dist. LEXIS 636 (N.D. Ga. Jan. 5, 2015)
by Author | Jan 26, 2015 | False Claims Act, Qui Tam
“Is there Whistleblower Protection from Retaliation?” is a question I am frequently asked as a Qui Tam Attorney.
Tim McInnis Esq.
The answer is “yes” provided you can meet some basic requirements. Here are ten important questions that will help you and your whistleblower lawyer know if you might have a viable whistleblower retaliation case against a current or former employer.
1. Did your current or former employer (or someone you did work for) do something harmful to you at your job? (Were you: fired, suspended, cut in pay, demoted, not promoted, transferred, ostracized or harassed?)
2. Did at least one of these things happen within the last three years?
3. Prior to the first harmful event had you done at least one of the following: (1) Ask questions or look for evidence about possible fraudulent or unlawful conduct that involved financial or business transactions with an agency or department of the U.S. Government? (2) Tell or report to your employer you thought they were committing fraud or doing something illegal? (3) Refuse to go along with something you thought was improper or illegal or tell others not to do so? (4) Contact government authorities? (5) Threaten or actually start a lawsuit alleging your employer had committed fraud or acted unlawfully?
4. Did your employer know or suspect that you had done any of the things listed above before they took the first adverse action against you?
5. Will you be able to rebut your employer’s likely explanation that what they did to you was for legitimate business reasons? (Saying you were part of a RIF or downsizing, or that you were sanctioned for misconduct, incompetency or not getting along with others.)
6. Do you have witnesses or documents (for example emails) or recordings to corroborate your allegations?
7. Are you sure you didn’t sign anything that might prevent you from suing your employer? (For example: an arbitration agreement, employment agreement, severance agreement, litigation/prior lawsuit release or union contract.)
8. Did you suffer financially and/or in some other way because of what your employer did to you? Have you kept records documenting any losses or expenses or medical issues? And, have you tried to mitigate your losses (such as diligently looking for a new job)?
9. Does your current or former employer still exist and have the resources to pay a judgment? (For example, they are not in bankruptcy or dissolved/out of business.)
10. Are you willing to go through a potentially long and stressful process to get legal redress?
Note: This is limited to whistleblower protection under the federal False Claims Act. There are state and city whistleblower protection laws, as well as ones for specific industries, like transportation, banking and finance, healthcare, energy and environmental protection. Each has its own requirements.
by Author | Dec 4, 2014 | False Claims Act, Qui Tam
A recent First Circuit appellate court decision makes it clear that “first” in the so-called “First To File Bar” of the False Claims Act, 31 U.S.C. § 3730(b)(5), means “first” not “best” or “better.” Section 3730(b)(5) states that, when a private party files a qui tam action under the False Claims Act, “no person other than the Government may intervene or bring a related action based on the facts underlying the pending action.” In the First Circuit case, the court ruled that a prior qui tam suit against Baxter Pharmaceutical, which had already been settled, barred a second law suit against the company by other relators. The court held that the two suits were similar enough to trigger the first to file bar and it did not matter that the second complaint had many more specific details than the first. The court’s reasoning focuses on whether the first complaint gave the Government sufficient information to start an investigation that could have uncovered the misconduct alleged in the second complaint. If it does the analysis ends there and the second suit must be dismissed.
Practice tip: If there was (or is pending) an FCA case against the same defendant that is similar to the one you are considering you may very well have to forego filing or at least go into it knowing that it is highly likely your second to file case will get tossed.
To read the Baxter opinion see UNITED STATES, EX REL. VEN-A-CARE OF THE FLORIDA KEYS, INC., Plaintiff, Appellee, v. BAXTER HEALTHCARE CORPORATION, Defendant, Appellee, v. LINNETTE SUN AND GREG HAMILTON, Appellants. UNITED STATES, EX REL. LINNETTE SUN; UNITED STATES, EX REL. GREG HAMILTON, Plaintiffs, Appellants, v. BAXTER HEALTHCARE CORPORATION, Defendant, Appellee. No. 13-1732, No. 13-2083, UNITED STATES COURT OF APPEALS FOR THE FIRST CIRCUIT, 2014 U.S. App. LEXIS 22564,December 1, 2014, Decided.
by Author | Jan 28, 2014 | Qui Tam
Settlement Announced: $320 Million Mortgage Fraud (HUD backed home loans). Taylor Bean & Whitaker Mortgage Corporation and Home America Mortgage, Inc. agreed to pay $320 million to settle a False Claims Act whistleblower case which alleged that the defendants had falsified loan applications, created false documentation, and misrepresented qualifications of applicants in order to secure federally-funded insurance for home loans that ultimately defaulted. The case is captioned: United States ex rel. Friddle and Kennedy v. Taylor Bean & Whitaker Mortgage Corporation et al., Civil Action No. 06-cv-3023-JEC (N.D. Ga.).
