Health care fraud schemes come in many different forms and are carried out by entities throughout the health care industry. Drug, device, and equipment manufacturers, health care providers (such as doctors and hospitals), laboratories, insurance companies, and others have defrauded government health care programs such as Medicare and Medicaid. The primary tools we use to bring qui tam cases in this area are federal and state False Claims Acts, Anti-Kickback Statutes, and Stark Laws. Our largest recoveries for our clients to date have been achieved in health care fraud cases.
The care a patient receives should be based on what is reasonable and necessary for the treatment of that patient — not whether their health care provider stands to benefit financially from choosing one treatment over another. To protect patients and taxpayer funds, the government has generally prohibited the use of kickbacks and banned conflicts of interest in health care delivery. Violating these tenets can give rise to False Claims Act liability.
Prescription pharmaceutical drugs play a huge role in the burdensome cost of our health care delivery system. The soaring costs of some drugs have received much Congressional and media attention, but the reality is that the complexities of the system and lack of true price regulation mean that this problem will continue to plague Medicare, Medicaid and other government health care programs. It also directly affects the pocketbook of patients who are obligated to pay out-of-pocket for often expensive co-pays and deductibles.
Medical devices and durable medical equipment are used to treat or assist patients in every health care setting and by every type of health care provider. From the most sophisticated device implanted surgically in a hospital to the most basic walker prescribed for a patient to use at home, fraudulent schemes put government health care funds and patient safety at risk.
Health care is provided in many settings by many different types of providers — hospitals, physician offices, ambulatory surgery centers, diagnostic testing facilities, skilled nursing facilities, laboratories, home health and hospice agencies, ambulance companies, behavioral health facilities, and more. In all of these contexts, fraudulent practices can and do occur. Complaints by whistleblowers have helped the government recover hundreds of millions of dollars stemming from fraud committed by health care providers.
Third parties who contract with health care providers but do not directly provide health care to patients may nevertheless engage in conduct that violates of the False Claims Act. For example, they may submit (or cause the provider to submit) fraudulent claims to government health care programs, or they may fail to return overpayments received from these programs. Most prominent among these players are third-party billers and electronic health or medical record software vendors.
More and more patients are enrolled in Medicare and Medicaid managed care plans offered by private insurers and paid for with government funds. Envisioned as a way to contain the rising costs associated with traditional Medicare and Medicaid, managed care is not immune to fraud. As fraudulent schemes are emerging, this area is increasingly a focus of government prosecutors using the False Claims Act.