Qui Tam / False Claims Act

Health care fraud remains a leading source of False Claims Act settlements and judgments. These recoveries restore funds to federal programs such as Medicare, Medicaid, and TRICARE, the health care program for service members and their families. But just as important, enforcement of the False Claims Act deters others who might try to cheat the system for their own gain, and in many cases, also protects patients from medically unnecessary or potentially harmful actions. The FCA is used to pursue matters involving a wide array of health care providers, goods, and services.

 

Unlawful Kickbacks

Kickbacks paid or received by health care providers undermine the integrity of federal health care programs by tainting medical decision-making, increasing health care costs, and adversely affecting competition. Federal law prohibits the willful solicitation or payment of illegal remuneration to induce the purchase of a good or service paid for by a federal health care program.

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Cases of unlawful kickbacks include, but are not limited to:

• Patient referrals in violation of the Anti-Kickback Statute (AKS) and the Stark Law

• Doctors violate the AKS and the Stark Law when  they receive improper remuneration from management service organizations (MSOs) in exchange for ordering laboratory tests from designated entities

• When companies offer physicians the opportunity to invest in these companies for the purpose of inducing them to refer their Medicare, Medicaid and TRICARE patients for medical treatment

• Kickback violations that include companies offering and paying kickbacks, including in the form of speaker honoraria, speaker training fees, consulting fees, and meals, to physicians who speak or attend the companies' programs, prescribe their drugs or use their medical equipment/supplies

• When durable medical equipment manufacturers provide unlawful kickbacks to DME suppliers to induce them to select their equipment

• When physician-owned hospitals sell shares to physicians, taking into account their volume or value of physician referrals when selecting the physicians to whom the shares would be resold and determining the number of shares each physician would receive

• When pharmaceutical companies provide illegal remuneration to prescribing physicians and their office staff, and for directing physicians to send their prescriptions to certain preferred pharmacies

• When a pharma company sets up a foundation as a conduit to pay illegal kickbacks in the form of copay subsidies so that it could market its pharmaceutical as “free” to doctors and patients while increasing its price significantly

• When companies pay kickbacks to Medicare beneficiaries by providing them “free” or “no-cost” diabetic testing glucometers and by routinely waiving or not making reasonable efforts to collect their copayments for glucometers and diabetic testing supplies

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Unnecessary Services and Substandard Care

The provision of unnecessary medical services not only wastes taxpayer funds but also can expose patients to harmful procedures and treatments or cause them to forego other potentially more effective treatments.

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Cases of unnecessary services and substandard cases include, but are not limited to:

• Medically unnecessary surgeries, especially when they endanger patient safety, create an excessive level of complications and negative outcomes, when surgeries are performed on candidates who were not appropriate for surgery, and or when medical providers fail to properly document their procedures and outcomes

• Claims of grossly substandard skilled nursing services

• When physicians are paid based on a productivity metric that provides a financial incentive to perform more surgeries of greater complexity

• Submitting false claims to Medicare for hospice services for patients who were not terminally ill

• Fraudulent claims for medically unsubstantiated medical devices

• Billing federal health care programs for unnecessary urine, drug, psychological, and genetic testing

• When facilities bill for rehabilitation therapy services provided as a result of aggressive corporate targets without regard for its patients’ actual clinical needs, resulting in the provision of medically unreasonable, unnecessary or unskilled services to Medicare patients.

 

Pharmaceutical Fraud

Cases involving pharmaceutical fraud include, but are not limited to:

• Submitting false claims to Medicare and Medicaid for prescription medications that the pharmacy had switched from lower-cost medications to higher-cost medications without any medical need and/or a valid prescription

• Inflated drug pricing. For example, manufacturing companies who sell active pharmaceutical ingredients and other products to compounding pharmacies cannot charge fraudulent and inflated Average Wholesale Prices. When these fraudulent prices are charged to its pharmacy customers, it causes those pharmacies to submit inflated compound prescription claims to Medicare, Medicaid and TRICARE

• Drug companies are violating the law when they knowingly underpay rebates to the Medicaid program by improperly designating a pharmaceutical as a “new drug,” as opposed to a preexisting drug for which they had significantly raised the price in years prior

 

Medicare Advantage Fraud

Cases involving Medicare Advantage fraud include, not are not limited to:

• Organizations participating in the Medicare Advantage (or Medicare Part C) program cannot knowingly submit or cause the submission of inaccurate information about the health status of beneficiaries enrolled in their plans to increase reimbursement