Khurana
Law Firm

Medicare whistleblower lawyer

Whistleblower and Qui Tam Lawyers Battling Medicare Fraud

Medicare fraud costs taxpayers billions of dollars each year. While most medical providers and drug companies are ethical and work within the system, there are those who don’t. When fraud happens, everyone loses. Medicare whistleblower lawyers help everyday citizens to file lawsuits on behalf of the government to report this kind of fraud. 

The federal government places a great deal of trust in medical and pharmaceutical providers. When that trust is ill-placed, it relies on private citizens to come forward to report abuse. People like you.  

Types of Qui Tam Cases
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Experienced Medicare Whistleblower Attorneys

At Khurana Law Firm, P.C., as experienced Medicare whistleblower lawyers, we support your heroic decision to come forward to report abuse and fraud in the industry. We know that coming forward is not easy and many things may be at stake. When you come to us, your case is held in the strictest confidence at all times.

With our extensive experience representing whistleblowers nationwide, we thoroughly investigate your claim, diligently prepare your case for court, and work tirelessly with you and the federal government to help bring fraudulent Medicare activity to justice.

Frequently asked questions

About Medicare Fraud

What is a Qui Tam Lawsuit?

A qui tam lawsuit is a civil lawsuit that is brought against a party committing fraudulent acts under the False Claims Act

The term “qui tam” derives from the Latin phrase, “Qui tam pro domino rege quam pro se ipso in hac parte sequitur” meaning “he who brings an action for the king as well as for himself.” A qui tam lawsuit is one in which a whistleblower brings forth a lawsuit on behalf of the government. If the lawsuit is successful and losses are recovered, the whistleblower will be entitled to a reward. 

In the fiscal year ending in September of 2020, the government recovered more than $2.2 billion from civil cases involving fraud and false claims. Of that figure, over $1.8 billion related to the healthcare industry. 

If you are a New York healthcare worker, get in touch with New York Medicare Whistleblower Attorney.

How Medicare Fraud is Detected and Brought to Justice?

Fraud detection relies on everyday individuals who come forward to report when they see things that are not right. The False Claims Act provides us with critical tools to identify Medicare fraud and hold the offending parties accountable. But it relies on people like you who care enough to report it. 

 

Any person with information concerning Medicare fraud can bring a qui tam lawsuit as a whistleblower. These can be employees who have witnessed fraudulent activity, a patient, a competitor, or anyone who has insight into the fraudulent activity that has taken place. As a Medicare fraud whistleblower, you may be entitled to 15 to 30 percent of the amount that the government recovers in the lawsuit. 

How Does it Work?

When fraud is reported, and evidence is gathered, your attorney files a lawsuit. This lawsuit is filed under seal, keeping it completely confidential. Only the federal government is aware of the lawsuit, and even the individual or entity being accused is not aware of the case. 

Documentation and evidence provides the federal government with essential information about the fraudulent activity. The case becomes public after the government investigates the alleged fraud and makes a decision whether to intervene in the case and then the Court unseals the case.

Why Would Someone Agree to Be a Medicare Whistleblower?

Medicare fraud hurts everyone, and whistleblowers are modern-day heroes on the front lines of protecting our healthcare system. In addition, a whistleblower stands to receive a substantial reward for his or her actions. 

If a defendant is found liable, they can be ordered to pay up to three times the losses caused to the government, as well as penalties for each false claim. A whistleblower is entitled to 15 to 25 percent of a recovery after the government becomes a party to the suit. If the government decides not to intervene, the whistleblower stands to be rewarded 25 to 30 percent of the recovery.

If you are an employee whistleblower, your job is protected, and you are protected against retaliation by the employer under the False Claims Act. If you are fired, harassed, or discriminated against by the employer because you filed a qui tam lawsuit, you are entitled to reinstatement, double back pay, and compensation for additional costs of litigation

What Constitutes Medicare Fraud?

Medicare fraud is when an individual or entity intentionally deceives Medicare in order to profit from it. Anyone can be party to Medicare fraud, from physicians, to pharmaceutical companies, to the beneficiaries themselves. Not only can Medicare fraud be investigated by the government under a civil lawsuit, but it is illegal at the federal level. Unfortunately, when greed is a factor, some healthcare providers and entities put their own gains above doing the right thing.

Who Can Be Found Liable in a Whistleblower Lawsuit?

Medicare fraud can take many different forms and can involve many different individuals and entities, including:

  • Individual healthcare providers, including physicians and nurses
  • Physician-owned groups and entities
  • Hospitals
  • Laboratories
  • Pharmacies
  • Pharmaceutical companies
  • Home health providers
  • Medical device providers
  • and others. 

If the government’s investigation finds individuals and entities potentially liable, they can face serious consequences. These can include financial recoupment to Medicare, civil fines, criminal indictment, attorneys’ fees, exclusion from all federal healthcare programs, and even time in prison.

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What is

Medicare Advantage Fraud

Medicare Advantage (MA) plans are privately run healthcare options offering Medicare-eligible individuals additional services that are not included in traditional Medicare. These organizations receive payment from Medicare for each of their members that vary according to their risk adjustment. Some Medicare Advantage organizations overestimate and exaggerate a member’s risk or a patient’s diagnoses to get higher payments from Medicare. They do this by:

Upcoding

The MA provider increases the severity of the patient’s condition, submitting a more serious diagnosis code to get paid by Medicare at a higher rate.

Chart reviews

The MA provider reviews charts to add additional diagnosis codes.

Chart mining

The MA provider mines patient’s charts to look for conditions that are not current but can put as current to increase their payments from Medicare.

Adding unsupported diagnosis

Coders are directed to add codes based on other information in the chart.

Not removing old diagnosis codes

The MA provider increases the severity of the patient’s condition, submitting a more serious diagnosis code to get paid by Medicare at a higher rate.

Sham RADV audits

The MA provider reviews charts to add additional diagnosis codes.

Incentivizing doctors

The MA provider mines patient’s charts to look for conditions that are not current but can put as current to increase their payments from Medicare.

Pre-filling charts

Coders are directed to add codes based on other information in the chart.

If you suspect Medicare Advantage Fraud, we are here to help.  Get in touch for a no-cost, completely confidential consultation today. 

What is

Overbilling, Upcoding, and Double-Billing

Medicare pays providers for many services using Evaluation and Management codes (E/M codes). Any intentional miscoding on a claim, such as upcoding, unbundling, or otherwise overbilling, is considered Medicare fraud. This includes:

Miscoding

Medicare will pay claims based on E/M codes for new patients at a higher rate because the visit usually requires more time than follow-up visits. Miscoding for a new patient or misusing billing modifiers to get additional reimbursement might be fraudulent.

Upcoding

When a medical provider uses a code that is inaccurate for a procedure or treatment in order to increase their reimbursement by Medicare, this is considered fraudulent activity.

Unbundling

When a provider separately codes procedures that are performed together to maximize reimbursement, it might be considered fraud.

If you know of fraud concerning overbilling, upcoding, or double-billing, you can report it here.

How works
Kickbacks and Illegal Relationships or Referrals
Khurana Law Firm, P.C.
Medicare Fraud
Medicare Fraud is a Serious Problem

While there are no exact figures concerning Medicare fraud, we do know it is a huge problem. In the fiscal year 2020, the government recovered over $1.8 billion in civil and fraud claims relating to the healthcare industry. 

$ 0
Recovered only in 2020
YOU, the healthcare worker, provide the most vital role in combating Medicare abuse and fraud.

Watching for fraud and abuse within your organization, practice, or provider’s office helps protect everyone from this taxpayer drain and holds abusers accountable.

So what is Medicare Fraud?

Fraud, as it relates to Medicare, is when individuals or entities make false statements or representations to benefit themselves at the expense of the Medicare program. 

Who defrauds Medicare?

Medicare fraud can involve numerous individuals, organizations, and entities, including physicians and nurses, physician-owned groups, drug companies, home health providers, medical device providers, nursing homes, and others.

How do people and companies commit Medicare fraud?

Fraud and abuse come in many different forms from coding abuses, to kickbacks, to altering records, to organized crime infiltration. Each method benefits the abuser while costing taxpayers billions. 

What laws protect Medicare from fraudulent activity?

The False Claims Act, Anti-kickback Statute, Stark Law, and Federal Criminal Healthcare Fraud Statute hold abusers accountable for their fraudulent activity. 

What government agencies protect against Medicare fraud?

Many government agencies strive to protect and promote the integrity of Medicare. These include the Centers for Medicare and Medicaid Services, Center for Program Integrity, US Department of Health and Human Services, and US Department of Justice, all attempting to keep Medicare fraud at bay. But they rely on people like YOU to be their eyes and ears.

How can I help?

If you see abuse and fraudulent activity you should report it. In some cases, you may even be entitled to a reward. To report Medicare fraud, contact the experienced whistleblower lawyers at Khurana Law Firm, P.C. for a confidential consultation. 

Types of

Medicare Fraud

Unnecessary Medical Services

Medicare will only pay for services and treatments that are considered “reasonable and necessary for the diagnosis or treatment of illness or injury.” This requires that healthcare providers exercise unbiased judgment that services are only provided when and to the extent that they are medically necessary. It may be in violation of the False Claims Act for a healthcare provider to seek payment under Medicare for services or equipment that is not medically reasonable or necessary.

If you know of providers who are getting reimbursed by Medicare for unnecessary medical services, contact us

Ineligible Home Health Services -- Physical, Occupational, and Personal Care Services

Medicare will only consider eligibility for home health care services if the recipient is homebound and under the care of a doctor who has certified the need. This includes services such as physical and occupational therapies, speech therapies, or intermittent skilled nursing care. 

If you have evidence of parties who Medicare is reimbursing for home health services that are not medically necessary, contact us to report it. 

Manipulations of Electronic Medical Records or Health Records (EMR or HER)

EMR and HER are digital records of patient charts that set out medical histories, prescription drugs, diagnostics, treatments, and results. These records are often integrated with billing systems to provide supporting documentation for services to ensure that they were necessary. Sometimes, these medical records are manipulated to provide false information justifying procedures and services that were medically unnecessary. 

If you know of EMR and HER manipulation relating to Medicare, report it here.

Pharmaceutical Company Fraud

The pharmaceutical industry is one of the largest recipients of Medicare dollars. Some of these companies engage in fraudulent practices, including kickbacks, physician incentives, and retaining providers as consultants or speakers on their behalf to promote their products. Some pharmaceutical companies will promote the use of their drugs for symptoms and conditions that the FDA did not approve. This can include incentivizing sales reps, paying kickbacks to physicians, or advising providers how to code to support off-label uses.  

If you have become aware of fraudulent activity by a pharmaceutical company, contact us

Pharmacy Benefit Managers and Medicare Part D Fraud

Pharmacy Benefit Managers, or PBMs, are third-party administrators of prescriptions under Medicare Part D plans. Private insurance companies that offer Medicare Part D provide prescription coverage to the beneficiaries, either directly or through these third-party managers. 

The benefit of PBMs is their ability to provide prescription drugs at a lower cost through many different means. However, fraud comes into play when these savings are not passed on to clients, when PBMs use formulas that are more favorable to more expensive drugs, or when they switch out the prescribed drug for generic or other brand names in order to collect more from Medicare.

If you are aware of fraud relating to PMBs and Medicare Part D, report it here

Laboratory Fraud

Laboratories that seek reimbursement from Medicare are required to review and maintain documents that justify the necessity of diagnostics and lab tests. Those that are not medically necessary are not eligible for Medicare reimbursement. Consequently, some labs forge diagnosis codes. Fraud and kickbacks have also been found between labs and physicians who agree to prescribe expensive and unnecessary panels. 

If you suspect laboratory fraud as it relates to Medicare reimbursement, contact us

Durable Medical Equipment

Just like any other services covered under Medicare, any durable medical equipment prescribed for a patient must be medically necessary. Billing for equipment that is not medically necessary, such as wheelchairs, prosthetics, oxygen tanks, and others, is considered fraud. Some of these are never even seen or used by the patients. 

If you have evidence of durable medical equipment fraud, report it here.

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Working with a Nationally Recognized Whistleblower Lawyer

When you become aware of Medicare fraud, you need the advice of an experienced whistleblower lawyer who can ensure that your claim is fully investigated and filed promptly and accurately. By working with an experienced attorney you are increasing the chances that the government will intervene, thus increasing your chances of a reward. Reporting Medicare fraud is a complex matter – don’t try to do this alone.

At Khurana Law Firm, P.C., we bring years of experience as national qui tam lawyers to your corner to help combat Medicare fraud. We are happy to review your case on a confidential, no-obligation basis. If we feel you have a valid claim, we represent you in a qui tam lawsuit to report the fraud and enable you to collect a reward. All whistleblower work is on contingency, so you pay nothing until there is a recovery. Contact us today to learn how we can help.