Whistleblower News & Articles
September 22, 2023
The Capitol Forum’s Healthcare Antitrust Weekly newsletter tackled the topic of Humana’s recent lawsuit against the U.S. government. The lawsuit challenges the federal government’s audit power. Humana is the second-largest Medicare Advantage insurance provider in the country. Like many other insurers, Humana was audited by the U.S. Department of Health and Human Services (HHS), Office of Inspector General. The audit found that Humana had overcharged the Medicare program $200 million in just one year!
After much debate, HHS finalized a rule that would strengthen its audit program. The rule would allow Medicare to recoup overpayments by extrapolating findings from audits. Humana, however, maintains that the government’s threat to collect those funds “upends the bargain at the foundation of the Medicare Advantage program.”
The Capitol Forum sought Erica’s perspective on the lawsuit. In her prior role as a federal prosecutor, Erica spearheaded investigations of two major Medicare Advantage insurers. One case yielded a $90 million settlement. The other is in litigation, with over $1 billion in damages alleged by the government.
Erica put Humana’s lawsuit in historical perspective, noting:
Humana’s lawsuit is the latest example of a decade-long industry effort to stymie attempts by the government to recover billions of dollars in excess payments to Medicare Advantage insurers. They are fighting tooth and nail to avoid paying those funds back to the taxpayers.
As many news outlets have reported, nearly every large Medicare Advantage insurer has been accused of fraud or rampant overbilling. The government has stepped up its efforts to use audits to reign in these overpayments. The recent lawsuit threatens to undermine those efforts. As a result, the False Claims Act remains a critical tool in the anti-fraud toolkit.
With suits like [Humana’s] threatening to squash or limit the effectiveness of the CMS audits, it is clear that the False Claims Act, a federal law that encourages whistleblowers to bring allegations of fraudulent overbilling to light on behalf of the government, is more important than ever.
Whistleblowers have already sparked hundreds of millions in recoveries in the Medicare Advantage arena — and there is surely more to come.
Combatting fraud in the Medicare Advantage program is a government priority. The DOJ emphasized this focus in a press release in February 2022.
Whistleblower Law Collaborative LLC, based in Boston, devotes its practice entirely to representing clients nationwide in bringing actions under the federal and state whistleblower laws and programs, False Claims Acts, and other whistleblower programs. We are in our 20th year representing whistleblowers in False Claims Act and other whistleblower matters. In fact, WLC was at the forefront of Medicare Advantage fraud cases, with its $137.5 million Wellcare settlement in 2012.
If you are considering becoming a whistleblower or are aware of other types of fraud, contact us for a free, confidential consultation.