Allegations Of Inflated Payments
Healthcare Provider Allegedly Claimed Patients Sicker Than They Were
Former Employee Blew Whistle
Health care providers defraud government programs like Medicare when they knowingly submit a claim for reimbursement that is based on false information, overcharge for or fail to provide an itemized service, or certify that a patient is eligible for the treatment received when in fact that patient is not eligible for the treatment. Fraud like this amounts to billions every year. Individuals with knowledge of the fraud – usually employees or patients – are authorized to bring actions on behalf of the government to recover from defrauding drug and device manufacturers, hospitals, physicians groups, clinics, labs and other providers. See False Claims Act (FCA), 31 U.S.C. §§ 3729 et seq. Cases brought under the FCA are known as “qui tams” and persons bringing these cases are referred to as “relators.” Relators can be rewarded 15-30% of the amounts and penalties recovered. 31 U.S.C. § 3730(d). If you have credible information of Medicare fraud or other false healthcare claims in Los Angelesor elsewhere in California, call us today at (415)441-8669 and we can help. Our toll-free number is 1-888-50EVANS (888-503-8267).
$90 Million Settlement Of Inflated Payments Allegations
On August 30, 2021 U.S. Department of Justice (DOJ) announced a settlement with a large California healthcare provider that has agreed to pay $90 million to settle allegations that it received inflated Medicare reimbursements to which it was not entitled. According to the complaint in a qui tam action, defe4ndant received inflated payments because it said people in its Medicare Advantage plans were sicker that they actually were. DOJ officials said the federal Medicare Advantage program makes larger payments for patients with more severe diagnoses. The government further claimed that the provider failed to correct the problem once it became aware that it had been submitting unsupported diagnoses codes, The total $90 million settlement includes $60 million in restitution to the government and a $30 million penalty. The provider also agreed to a five-year “corporate integrity agreement” that requires outside groups to review patient records and diagnoses. The whistleblower in the case was a former employee at one of the provider’s facilities and will receive 15-30% of the $90 million settlement as a reward for blowing the whistle on the defendant’s practices. Her qui tam suit was originally filed six years ago.
How Qui Tam Cases Work
Qui tam cases typically take a long time but they all begin with filing a qui tam complaint under the FCA in the federal district court where the allegedly fraudulent conduct occurred. 31 U.S.C. § 3730(b). The complaint is filed confidentially under seal and the government has sixty days to review the allegations and decide whether to intervene. This review period can be extended, and often times is, for a year or more as the government continues to investigate the allegations. If the government decides to intervene, as in the reported case, the government essentially takes over the litigation. 31 U.S.C. § 3730(c). If the government decides not to intervene, the relator has the right to continue the litigation on his or her own. If the relator continues the litigation alone, he or she receive a larger percentage of the amount the government eventually recovers. 31 U.S.C. § 3730(d). The relator may also pursue claims for wrongful retaliation against the defendant if the relator were fired or demoted as a result of blowing the whistle. 31 U.S.C. § 3730(h).
If you have credible information of government contractor fraud against Medicare or Medi-Cal call Ingrid M. Evans at (415) 441-8669, or toll-free at 1-888-50EVANS (888-503-8267) or by email at <a href=”mailto:firstname.lastname@example.org”>email@example.com</a>. In addition to FCA and CFCA whistleblower cases, Ingrid and Evans Law Firm, Inc. also handle bank fraud whistleblower cases under FIRREA/FIAFEA, commodity trading and securities fraud under the Commodities Futures Trading Commission Whistleblower Program and the Securities and Exchange Commission Whistleblower Program, and tax fraud under the Internal Revenue Service Whistleblower Program.
 Evans Law Firm, Inc. was not involved in the cases in any way.