The human population is growing at a rapid pace, and in the U.S., this growing population is also aging. The babies born after the Second World War, often referred to as “Baby Boomers,” are now reaching retirement age and eligible for Medicare. The Kaiser Family Foundation reports that almost 10,000 Baby Boomers turn 65 on a daily basis! That’s almost 90 million Baby Boomer eligible for Medicare by 2050. Read Moreabout Baby Boomers & Medicare Fraud
After receiving a hefty check in settlement of a False Claims Act case, one of our client relators presented us with a mug saying “G-D Bless NAMFCU.” He wanted to recognize the vital role that NAMFCU played in the investigation, prosecution and settlement of his case. But most relators, especially at the outset of their case, do not know anything about NAMFCU (pronounced Nam-Foo-Koo), or how that organization plays a vital role in assisting relators pursue Medicaid fraud claims brought through a qui tam case. Read Moreabout The False Claims Act and the National Association of Medicaid Fraud Control Units (NAMFCU)
SCOTUS to decide the issue of “implied certification” in Universal Health Services v. United States ex rel. Escobar
On December 4, 2015, the Supreme Court granted the defendant United Health Services’ Petition for a Writ of Certiorari to decide, among other things, the issue of whether the “implied certification” theory of legal falsity under the False Claims Act is viable.
Escobar involved a teenaged girl, a Medicaid beneficiary, who was treated by unlicensed workers who had held themselves out to be social workers, psychologists, and psychiatrists, when they were nothing of the sort. Treatment by these workers led to the girl’s death when she was prescribed a drug that caused her to have seizures, one of which was fatal.
ACA (the Affordable Care Act) expanded healthcare coverage to millions of low-income Americans and put in place numerous reforms within the health insurance sector. Currently, updates to healthcare delivery systems and financing methodologies implemented since ACA was enacted are predicted to result in dramatic reductions in unnecessary medical care in this country. But still, an avalanche of fraud continues to harm healthcare programs, and in particular government programs like Medicare and Medicaid.
Fortunately, powerful anti-fraud provisions in ACA and the False Claims Act have led to revocation of billing privileges for tens of thousands of providers who cheated the government, and Medicare claims are now routinely screened using advanced computer algorithms before being paid. These measures, combined with continued financial incentives for qui tam whistleblowers (called “Relators” under the False Claims Act), will help prevent healthcare fraud and ensure that healthcare coverage post-ACA is provided in a reasonable and cost-efficient manner.
This June, federal officials announced the largest coordinated criminal Medicare fraud action and the first large-scale effort focused on Medicare Part D fraud in the history of the U.S. Justice Department. The Medicare Fraud Strike Force levelled charges against 243 individuals across the country accused of falsely billing $712 million to Medicare in a number of separate schemes. Those charged with fraud under the False Claims Act included 46 doctors, nurses and other licensed medical professionals.
As front-line professionals responsible for dispensing medications to Medicaid beneficiaries, pharmacists are particularly well positioned to discover and report Medicaid fraud. As a result, pharmacists have initiated a number of highly successful qui tam actions under the False Claims Act. Time after time, successful qui tam whistleblower actions by pharmacist relators have successfully recovered taxpayer funds.
Healthcare is the largest single cost in the federal budget – approximately 22 percent of the total — and the cost increases dramatically from year to year. With fraud following that money, the government is highly incentivized to investigate and prosecute corruption in the healthcare and pharmaceutical industries.
False Claims Act violations involve making fraudulent medical billing claims for payment from the government healthcare programs. One of the largest programs is Medicaid, healthcare for the indigent. Fraudulent conduct can involve overbilling, or receiving payments under these programs while not in compliance with healthcare regulations. Qui tam law suits brought by Medicaid fraud attorneys have recovered billions of dollars from companies committing health care fraud.
More than $30 billion has been recovered in Federal civil actions under the False Claims Act (“FCA”) since the statute which originated in the Civil War era, was amended in 1986 to provide enhanced rewards and protections for qui tam whistleblowers.
In fiscal year 2014, $5.69 billion in fraud against the government was recovered for taxpayers. Most of these cases were brought by qui tam relators, whistleblowers who come forward with their qui tam attorneys to report alleged fraud, and can receive 15-to-25 percent of the recoveries. This was another record year for Federal False Claims Act recoveries, according to the U.S. Department of Justice.
Without qui tam whistleblowers, billions of dollars of fraud payments or demands for payment hidden from the Government would have gone unnoticed. This stolen money would have remained in the pockets of individuals and entities responsible for the frauds, but courageous whistleblowers stepped up to return defrauded dollars to the U.S. Treasury and, as a result, shared in those recoveries.
The Department of Justice (DOJ) recently announced that it has collected a record $5.69 billion in settlements involving fraud and false claims against the government for fiscal year 2014. The largest recoveries were in mortgage fraud and healthcare fraud, where the government obtained $3.1 billion and $2.3 billion respectively. Recoveries in qui tam whistleblower cases (actions brought by a whistleblower, known as a relator) totaled nearly $3 billion.
“It has been an extraordinary year for civil fraud recoveries, but the true significance is not in breaking records or making history; it is in the billions of dollars restored to the federal treasury,” said Acting Assistant Attorney General Joyce Branda.
On November 4, 2013, after nearly six years of litigation, Johnson & Johnson, the self-proclaimed “family company,” agreed to pay $149 million to the federal government, the states of California, Kentucky, Indiana, and Massachusetts, and the Commonwealth of Virginia, to settle Medicaid fraud claims under the False Claims Act. (Johnson & Johnson Press Release)
The qui tam action alleged that pharmaceutical manufacturer Johnson & Johnson paid Omnicare pharmacies kickbacks for switching nursing home patients from their anti-psychotic to the Johnson & Johnson product Risperdal® to significantly increase sales and profits. Omnicare is the largest pharmacy supplying drugs to nursing homes in the United States. The qui tam lawsuit was brought by Chicago whistleblower law firm Behn & Wyetzner, Chartered and led by qui tam lawyers Linda Wyetzner, Michael Behn, and William W. Thomas. The Philadelphia whistleblower law firm of Kenney & McCafferty, P.C. also worked on the case.