There are many issues facing the healthcare industry in the US, from lack of transparency to the rising cost of care. One issue that is, unfortunately, growing increasingly popular is fraud. Healthcare fraud includes billing for services that were not rendered, "upcoding" (billing for a more expensive service than was actually provided), and other false or misleading billing practices. This can happen in many areas of the healthcare industry, including among drug manufacturers, medical equipment sales, managed care providers, hospice and nursing homes, pharmacies, laboratories, and individual physicians. Healthcare fraud wastes billions of dollars each year, affecting both the private and public healthcare industry, and drives up healthcare costs for everyone.
Thankfully, there are ways to help the US government combat healthcare fraud. Through the qui tam provision of the False Claims Act, normal citizens can become whistleblowers who play a key role in bringing healthcare fraud to light. The False Claims Act focuses only on fraud committed against the US government, so by coming forward and exposing fraudulent practices, whistleblowers can help save taxpayers money. They also help ensure that government healthcare resources are used appropriately. Whistleblowers not only help the US government, but they can also receive a reward. If the information provided by a whistleblower leads to a successful case where the government recovers the money that was lost or wasted because of the fraud, the whistleblower may be eligible to receive between 15% and 30% of the recovered money.
For example, in April of 2022, the Department of Justice announced it was settling a claim against Florida’s BayCare Health System and Hospital Affiliates for $20 million. The allegations involved BayCare making improper donations to the Juvenile Welfare Board of Pinellas County, who in turn improperly funded the state’s share of Medicaid payments to BayCare. Medicaid is meant to be funded by both federal and state governments and is not supposed to receive “non-bona fide” donations like the ones given by BayCare. In this case, the donations given by BayCare were returned in the form of larger shares of Medicaid payments which, between 2013 and 2015, amounted to $20 million. This information came to light when a former hospital reimbursement manager filed a qui tam action on behalf of the US government. As a reward, this person received $5 million or 25% of the money recovered through the lawsuit.
One of the biggest cases in recent years involves Indivior Solutions and their marketing of the opioid-addiction treating drug Suboxone. This drug was approved for and marketed as a treatment for opioid addicts that can help with their withdrawal symptoms. Ironically, the drug itself contains buprenorphine, which is a powerful opioid. Through a scheme involving its marketing and sales team, Indivior Solutions managed to expand Medicaid coverage of Suboxone by falsely indicating that it had the lowest rate of accidental exposure to children of all buprenorphine drugs. In addition, the sales force for Suboxone promoted the drug as being less susceptible to abuse. By providing misleading information that downplayed this risk and getting approved for Medicare coverage, Suboxone was able to be prescribed at a higher rate. The sales force also promoted the drug to physicians who were more likely to prescribe it to patients with no legitimate medicinal purpose. All these allegations combined resulted in both a criminal and civil investigation, and Indivior Solutions had to pay more than $600 million to settle the matter.
These are just some of the many successful qui tam cases that the Department of Justice has brought forward with the help of normal citizens. In the 2021 Fiscal Year alone, more than $5.6 billion has been recovered by the federal government. This is the second-largest annual total since the False Claims Act was modernized and reinforced in 1986. Of those $5.6 billion recovered, over $5 billion were from matters involving healthcare fraud. These cases are just some of many examples of how whistleblowers can be vital in the fight against healthcare fraud. Through the False Claims Act, law-abiding citizens with information regarding misconduct in the healthcare system can be rewarded for becoming whistleblowers. If you know of healthcare fraud, consider speaking out. You may be able to make a difference.
If you know about Healthcare Fraud you believe the public and government do not know about, please contact our firm, Piacentile, Stefanowski & Associates LLP, also known as Whistleblowers International. Our attorneys and investigators will evaluate your matter free of charge and may be able to help.