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Oct 29, 2021 by |

Orange County Whistleblower Attorney: $90 Million Settlement Of Medicare Advantage Fraud Allegations


Allegations Of Submission Of False Diagnosis Codes

Provider Allegedly Failed To Monitor Compliance

Office Staff Member Blew Whistle 

Health care fraud against private insurers and government programs like Medicare and Medicaid (called Medi-Cal here in California) amounts to billions every year. Every year private individuals recoup more of this lost money for the government than the government itself does. That’s because individuals with knowledge of the fraud – usually employees or patients – are authorized to bring actions on behalf of the government to recover money paid out to providers on fraudulent claims. See False Claims Act (FCA), 31 U.S.C. §§ 3729 et seq.  These cases are known as “qui tams” and the plaintiffs 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 Orange County or 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).

Inflated Payments Case Settlement

On August 30, 2021 U.S. Department of Justice (DOJ) announced a settlement of $90 million with a large health care provider to settle allegations that it received inflated Medicare reimbursements to which it was not entitled.[1] According to the complaint in the case, the health care provider received inflated payments because it used codes in its Medicare Advantage claims for reimbursement the indicated the treated patients were sicker than they actually were. The government referred to this practice as “code chasing.”  The government further alleged failure of the organization to conduct adequate internal monitoring and respond to, or follow up with, the results of both internal and external auditing efforts to correct these aggressive code chasing activities. 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 Individuals Initiate A Qui Tam Case

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).

Contact Us

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=””></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. 

[1] Evans Law Firm, Inc. was not involved in the cases in any way.


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