Medicaid and Medicare Upcoding and Hospital Fraud Whistleblower Claims

Medicaid and Medicare Upcoding and Fraud Whistleblower Lawsuits (Upcoding Qui Tam Claims, Mischarging for Services Claims, Double Billing Qui Tam Claims, Illegal Kickback Qui Tam Claims, & Other Medical Service Provider Fraud Claims)

Healthcare fraud costs taxpayers an estimated $100 billion each year. Illegal Kickbacks, Upcoding, Double Billing, False Coding, and fraudulent mischarging of health care services are just a few ways that fraudulent medical providers are able to defraud Medicare, Tricare, the Veterans' Administration (VA), and other government services out of billions of dollars. Heroes including health care administrators, doctors, nurses, and therapists are stepping forward and blowing the whistle on Tricare, the Veterans' Administration (VA), and Medicare billing fraud including manipulation of outlier payments to Medicare, kickbacks, upcoding, or bill padding. If you are a healthcare professional that is aware of fraud, please become a Tricare, Veterans' Administration (VA), Medicaid, or Medicare Whistleblower. 

 

Health Care Fraud Upcoding Whistleblower Law Suits (Medicare, VA, and Tricare Upcoding Qui Tam Whistleblower Claims)

Upcoding occurs when a medical service provider intentionally and fraudulently upcodes services to obtain a higher reimbursement than one that is entitled to for the service that was actually provided. In both the Medicare and Medicaid systems a set of billing codes is used by healthcare providers to bill for services. These codes are known as the Healthcare Common Procedure Coding System (HCPCS). A service provider that intentionally uses a higher paying code to fraudulently reflect that a more expensive procedure or device was involved in the patient’s treatment than actually was used or was necessary. A pattern of intentional upcoding treatment can result in large profits for the healthcare provider, but also cost taxpayers millions of dollars.

Upcoding fraud is typically hard to catch without the help of persons with inside information because that Healthcare Common Procedure Coding System (HCPCS) codes are billed electronically and can easily slip through the system. Therefore unless the upcoding is caught through a random audit (approximately 2% of the claims per year are audited), it is up to insiders, informants, heroes, and health care professionals to catch fraudulent upcoding.

Another type of coding fraud is “unbundling”, where bundled related procedures or composite lab tests are run together, but billed separately by the lab or healthcare provider to obtain more compensation. These types of billing fraud also allow healthcare providers and labs to make higher profits by bilking Medicare, Medicaid, and taxpayers out of millions of dollars. These unbundling fraud schemes are also hard to detect without someone that is familiar with the codes and billing.

 
Qui Tam Whistleblower Plaintiffs have received over $1 Billion in Awards of the over $12 Billion in Recoveries for Exposing Fraud Against the United States Government (Qui Tam Plaintiff Whistleblower Claims)

Medicaid, Tricare, Veterans Administration, Hospice, and Medicare Whistleblowers that provide original source information of schemes to fraudulently take money from our United States government including upcoding, double billing, bill padding, unbundling, and charging for services never provided may recover a portion of the proceeds recovered on the government's behalf. Since 1986, relators have recovered over $1 billion for helping expose fraud against the United States government.

Below is an excerpt from the False Claims Act explaining what types of awards qui tam whistleblowers may recover for being the "original source" of information that is used to successfully expose fraud against Medicaid, Tricare, Veterans Administration, Hospice, Medicare, or another subdivision of the United States Government and recover money from the parties committing the fraud.

(d) AWARD TO QUI TAM PLAINTIFF

(1) If the Government proceeds with an action brought by a person under subsection (b), such person shall, subject to the second sentence of this paragraph, receive at least 15 percent but not more than 25 percent of the proceeds of the action or settlement of the claim, depending upon the extent to which the person substantially contributed to the prosecution of the action. Where the action is one which the court finds to be based primarily on disclosures of specific information (other than information provided by the person bringing the action) relating to allegations or transactions in a criminal, civil, or administrative hearing, in a congressional, administrative, or Government [General] Accounting Office report, hearing, audit, or investigation, or from the news media, the court may award such sums as it considers appropriate, but in no case more than 10 percent of the proceeds, taking into account the significance of the information and the role of the person bringing the action in advancing the case to litigation. Any payment to a person under the first or second sentence of this paragraph shall be made from the proceeds. Any such person shall also receive an amount for reasonable expenses which the court finds to have been necessarily incurred, plus reasonable attorneys’ fees and costs. All such expenses, fees, and costs shall be awarded against the defendant.

(2) If the Government does not proceed with an action under this section, the person bringing the action or settling the claim shall receive an amount which the court decides is reasonable for collecting the civil penalty and damages. The amount shall be not less than 25 percent and not more than 30 percent of the proceeds of the action or settlement and shall be paid out of such proceeds. Such person shall also receive an amount for reasonable expenses which the court finds to have been necessarily incurred, plus reasonable attorneys’ fees and costs. All such expenses, fees, and costs shall be awarded against the defendant.

Since amendments were made to the Federal False Claims Act in 1986, citizens that have filed suits on behalf of the federal government against government contractors that have participated in defrauding the government have regained over $12 Billion for taxpayers as well as have collected over $1 Billion in qui tam whistleblower awards.

Government Contractor Fraud Qui Tam Whistleblower Lawsuit Information (False Claims Act Whistleblower Qui Tam Action Information)

For more information on Medicare Fraud, Tricare Fraud, Medicaid Fraud, Defense Contractor Fraud, Off Label Fraud, Road Construction Fraud, and other types of False Claims Act Whistleblower Claims, please go to the Qui Tam, Whistleblower, and Federal Federal False Claims Act Information Center or the following webpage on Medicaid and Medicare Upcoding & Fraud Whistleblower Lawsuits (Upcoding Qui Tam Claims, Mischarging for Services Claims, Double Billing Qui Tam Claims, Illegal Kickback Qui Tam Claims, & Other Medical Service Provider Fraud Claims) .

Medicare Fraud and Medicaid Fraud Estimated at about $65 Billion a Year

Recent estimates from the Federal Government suggest that Medicare Fraud is approaching $50 Billion each year and Medicaid Fraud is approaching $20 Billion each year.  As a result of this fraud and the need to reduce medical expenditure, the Federal Government including the United States Department of Justice has been cracking down on Medicare Fraud, Medicaid Fraud, VA Fraud, and other forms of fraud that have been committed against the United States.  Not only is the United States Government increasing law enforcement efforts to arrest criminals and requiring stricter documentation to obtain Medicare Payments and Medicaid Payments, but the Federal Government has expanded the Federal False Claims Act and is encouraging qui tam whistleblowers to come forward to report Medicare Fraud and Medicaid Fraud.

Illegal Kickbacks, Upcoding, Double Billing, False Coding, and fraudulent mischarging of health care services are just a few ways that fraudulent medical providers are able to defraud Medicare, Tricare, the Veterans' Administration (VA), and other government services out of billions of dollars.  Heroes including health care administrators, doctors, nurses, and therapists are stepping forward and blowing the whistle on Tricare, the Veterans' Administration (VA), and Medicare billing fraud including manipulation of outlier payments to Medicare, kickbacks, upcoding, or bill padding.  

For more information on Medicare Fraud, Medicaid Fraud, or other Fraud against the United States, please go to the following websites: Medicare Fraud and Medicaid Fraud Lawsuits and Nursing Home Medicare Fraud Skilled Nursing Facilities (SNF) Lawsuits.

Qui Tam Defense Contractor False Certification Whistle Blower Claim Lawsuits

Common Types of Defense Contractor Fraud and False Certifications that Lead to False Claims Act Lawsuits

Defense contractor fraud is a common way that government contractors defraud the United States Government and taxpayers out of large amounts of money. Many whistle blowers have been successful in blowing the whistle on fraudulent defense contractors to reveal fraud schemes that put our troops in danger and steal money from the United States. Under False Claims Act litigation billions of dollars are regained from these fraudulent defense contractors. Some common ways defense contractors cheat the government are False Certification of Product Quality, Product Substitution, Cross Charging, False Certification of Services Provided, Charging for Services or Goods not provided, and Violations of the Truth-in-Negotiations Act ("TINA"), and Improper Cost Allocation.

False Certification of Product Quality commonly occurs after a product has been approved for mass production. The original prototypes of a product are typically created with high quality materials and parts including strong metals, seals, plastics, and components. However, after the original prototypes have been tested and approved, some defense contractors use inferior parts and materials to lower costs that make weapons, ships, vehicles, computers, electronics, and other military goods less reliable, weaker, and more prone to not work when needed. The defense contractor that provides a false certification of a product's quality has committed a false certification that may subject the defense contractor to a False Certification of Product Quality False Claims Act Law Suit.

The Defense of Department often requires its contractors to build weapons systems in accordance with very detailed product specifications because quality and reliability are critical with weapons systems and other military equipment. Failure to comply with these specifications and falsely certifying that these specifications were met can cause death and place our troops in danger. As such it is extremely important that appropriate quality assurance steps are taken in building or producing weapons systems and other military equipment and that a defense contractor's certification of compliance with these specifications can be trusted.

Similar to False Certification of Product Quality Qui Tam Claims are Product Substitution False Claims. These claims occur when a Defense Contractor that is under a government contract that specifies that the defense contractor build products using a certain grade, quality of parts, or materials & parts from American companies, fails to comply with the contract. These Defense Contractors often decide it is more profitable to use or substitute inferior parts or parts not made by American companies. Defense Contractors that use inferior parts or parts not made by American Companies as required by their government contract may be subject to a Product Substitution False Claim Act Law Suit.

Cross-Charging occurs when a Defense Contractor has a fixed-price contract, where the company receives a fixed price for a certain number of weapons no matter how much it costs to produce them and another that is a "cost-plus" contract, where the government pays the company for the cost of making the weapons, plus a percentage of its costs as a profit. In this circumstance the Defense Contractor has an economic incentive to charge the time it spends working on the fixed-price contract (where it gets paid the same no matter how much time it takes) to the cost-plus contract (where it gets paid for its costs plus profit). This may be accomplished by instructing employees to write down on their time cards that they worked on the cost-plus contract when they actually worked on the fixed-price contract. A Defense Contractor that charges fixed price work on a cost-plus contract is creating false claims or false certifications that may subject them to a Cross-Charging False Claims Act Law Suit.

Improper cost allocation false claims are a more subtle version of the cross-charging scheme. In this type of false claim, a defense contractor with government contracts and private commercial contracts fails to spread or allocate their costs fairly among the different jobs. These types of false claims are typically more difficult to detect as the defense contract usually tries to hide the misallocation in indirect costs or bury the misallocations in hard to interpret records. These improper allocation false claims are more common in large contracts where the product has military uses and private uses such as with large aircraft companies. Defense Contractors that deliberately allocate a disproportionate share of indirect or overhead costs to the government for the purpose on increasing there profits may cause themselves to be subject to Improper Allocation False Claims Law Suits, if the correct whistle blower reports the fraud.

When the government wants to purchase highly specialized weapons, military services, or other military equipment, it often is limited to one potential defense contractor because of the specialized need. This limited supply often creates monopoly power in the "sole-source supplier". This creates a problem in making sure that the sole-source supplier does not over charge the government for the good or services that it is supplying to the government. The Truth In Negotiation Act (TINA) requires the Defense Contractor to truthfully disclose all relevant information about its costs to the government in sole-source contract negotiations. Defense Contractors that submit false cost and pricing data to the Defense Department or failure of a sole-source Defense Contractor to provide accurate cost information to intentionally inflate costs to increase profits can cause liability for a violation of the Truth In Negotiation Act and result in a Truth In Negotiation Act Violation False Claims Act Law Suit.

Qui Tam Defense Contractor False Certification Claim Lawsuits, Defense Contractor Fraud Lawsuit Lawyers, and Other Qui Tam Claim Lawsuits

For more information on Qui Tam Claim Lawsuits and Qui Tam False Certification Lawyers, click on the following links: defense contractor false certification claim lawsuits, health care provider claim lawsuits, financial institute claim lawsuits, or other large contractor or subcontractor claim lawsuits.

Whistleblowers, American Heroes, and Qui Tam Claims

Whistleblowers, American Heroes, and Qui Tam Claims

During the Civil War, corrupt military contractors were defrauding the United States Army out of hundreds of thousands of dollars and putting troops at risk by supplying troops with defective products and faulty war equipment. Illegal price gouging was a common practice and the armed forces of the United States suffered. In response, Abraham Lincoln enacted the Federal Civil False Claims Act. A key provision of the act was known as qui tam.

The abbreviation is from Latin and refers to "a person who files a suit for the king as for himself". Qui tam laws have existed for centuries as deceptive government contractors have been around as long as government contracting has. Qui tam actions allow a private citizen to file a lawsuit on behalf of the U.S. government in an effort to recover losses caused by fraud against the government. The law is an incentive for civilians who know of individuals or companies making false claims for profit to come forward with information. In reward, the "whistleblower" (also known as the relator) shares in any federal revenue recovered.

If you are aware of a defense contractor, highway contractor, large health care company, or other large contractor or subcontractor that is defrauding the United States Government out of millions or billions of dollars, contact Texas Qui Tam Lawyer Jason Coomer.

History of Qui Tam Claims

In 1986 as a result of increased government contractor fraud, Congress amended the False Claims Act in order to make it easier for whistleblowers to file claims against fraudulent corporations and individuals.

The 1986 Amendment defines a "claim" as:

"...any request or demand which is made to a contractor, grantee, or other recipient if the United States Government provides any portion of the money or property which is requested or demanded, or if the government will reimburse such contractor, grantee, or other recipient for any portion of the money or property which is requested or demanded."

The whistleblower's share of recovery is a maximum of 30 percent and the government's prior knowledge of fraud now does not necessarily bar a whistleblower from collecting lost revenue. If the government took over the lawsuit, the relator can "continue as a party to the action." The defendant is also required to pay for the relator's attorney fees. The whistleblower is also protected from retaliatory actions by his or her employer. As a result or the amendment, qui tam lawsuits increased dramatically. Though the amendment was first made fore corrupt defense contractors, the amendment has uncovered billions of dollars in health care fraud.

Anyone who defrauds the government out of revenue can be held accountable under the False Claims Act. Common defendants include defense contractors, health care providers, other government contractors & subcontractors, state and local government agencies, and private universities. Whistleblowers often include current and former employees of the defrauding company, competitors of government contractors and public interest groups.

The False Claims Act was enacted to encourage private citizens to assist the government in the fight against fraud. Often the whistleblower faces an uphill battle as large, powerful corporations or individuals are usually named as defendants. An experienced attorney in qui tam claims may help you gain a percentage of stolen government funds.

Qui tam actions typically revolve around false claims that are either directly or indirectly presented to the Government for "payment or approval." These false claims can be generated through the submission of false bills, records, statements or other representations made to the Government.

There are several types of Qui Tam claims covered under the False Claims Act:

• Mischarging or overcharging for goods or services.

• Improper price data and the request for payment for services never provided.

• Holding government property for fraudulent purposes.

• Avoiding payment of a debt to the government because of illegal reasons.

• Knowingly providing the government with defective or dangerous products that were falsely certified.

• Falsely certifying information for the entitlement of benefits.

• Having any false claim paid by the government.

The mischarging case is the most common type of qui tam case filed. Mischarging cases generally involve filing false claims for goods or services that were not provided or delivered. A common mischarging scenario is employee labor charged to a government contract not worked on. Other common mischarging schemes are claims made to the Government for medical services not rendered or for services performed by an attending physician when the service was actually performed by a nurse or other provider that should have been billed at a lower rate.

Another type of case is the false negotiation or defective pricing case that involves the submission of false cost and pricing data to the Government. This scheme, which takes on many forms, involves the submission of false costs or pricing data to the Government during the negotiation of a contract that subsequently results in an inflated contract price.

Other common types of cases involve product and service substitution and false certification of entitlement for benefits. Examples of product and service substitution are falsely certifying that a product meets specifications, false testing schemes such as falsely certifying that reliability testing was conducted and providing an inferior service or product. Examples of false certification of entitlement cases are falsely certifying information for FHA mortgage guarantees and price supports.

Potential heroes that blow the whistle on government fraud and corruption include employees, former employees, high-level executives, sub contractors, general contractors, and people working with major defense contractors, telecommunications companies, and large health care organizations.

Blowing the Whistle on Those that Commit Fraud Against the United States Government, First to File Provisions of the Federal False Claims Act, and Preserving Relator Rights to Share in Recovery of Funds (Qui Tam Federal Government Contractor Fraud Whistle Blower Claims)

If you are a Health Care Administrator, Hospital Administrator, Nursing Home Administrator, Doctor, Coder, Benefit Coordinator, Nurse, Chief Financial Officer, or other health care professional that has knowledge and evidence of a Health Care Provider, Hospice Provider, Nursing Home, Hospital, Medical Supply Company, or other health care contractor or subcontractor that is defrauding Tricare, Medicare, or the United States Government out of millions or billions of dollars, it is important to gather evidence of the fraud and blow the whistle on the fraud.

In blowing the whistle on government contractor fraud, subcontractor fraud, defense contractor fraud, off label drug fraud, patent fraud, health care fraud, Medicare fraud, Tricare fraud, VA fraud, or other fraud against the government, it is typically best to contact a Federal Government Contractor Fraud, Medicare Fraud, Tricare Fraud, and Hospice Fraud Qui Tam Claim Lawyer like Jason S. Coomer and the firms that he works with to help investigate the fraud and pull together a disclosure and complaint to file.

For information on this web site or Qui Tam Whistle Blower Litigation, feel free to contact Medicare Fraud, Tricare Fraud, and Hospice Fraud Qui Tam Claim Lawyer, Jason S. Coomer.