If the government is able to substantiate allegations of Medicare fraud, it will initiate a civil or criminal lawsuit. If the federal government is proceeding with civil charges, it may issue a civil investigative demand (CID). A CID is a type of administrative subpoena that federal agencies can issue without first obtaining judicial approval.
Full Answer
Did Kaiser Permanente violate False Claims Act?
The United States has intervened in six complaints alleging that members of the Kaiser Permanente consortium violated the False Claims Act by submitting inaccurate diagnosis codes for its Medicare Advantage Plan enrollees in order to receive higher reimbursements.
Can the government intervene in a False Claims Act case?
The False Claims Act also permits the government to intervene in such lawsuits, as it has done, in part, in these cases. The cases are consolidated in the Northern District of California and captioned United States ex rel. Osinek v.
How much money does the federal government pay Medicare Advantage plans?
“The federal government pays hundreds of billions of dollars every year to Medicare Advantage Plans,” said Acting U.S. Attorney Matt Kirsch for the District of Colorado. “The District of Colorado will vigorously pursue investigations with our partners to make sure that money supports necessary health care, not fraud.”
Can Medicare Advantage defraud be proven?
“The Medicare Advantage Program maintains the health of millions, and wrongful acts that defraud the program cannot continue and will be pursued.” “The federal government pays hundreds of billions of dollars every year to Medicare Advantage Plans,” said Acting U.S. Attorney Matt Kirsch for the District of Colorado.
What is the federal False Claim Act?
Whistleblower Protection Under the False Claims Act The federal False Claims Act protects employees who report a violation under the False Claims Act from discrimination, harassment, suspension or termination of employment as a result of reporting possible fraud.
Which is an example of Medicare abuse?
One example of Medicare abuse is when a doctor makes a mistake on a billing invoice and inadvertently asks for a non-deserved reimbursement. Medicare waste involves the overutilization of services that results in unnecessary costs to Medicare.
What is an individual called who files a lawsuit on behalf of the federal government?
Definition. In a qui tam action, a private party called a relator brings an action on the government's behalf. The government, not the relator, is considered the real plaintiff. If the government succeeds, the relator receives a share of the award.
What is Medicare abuse?
Abuse describes practices that may directly or indirectly result in unnecessary costs to the Medicare Program. Abuse includes any practice that does not provide patients with medically necessary services or meet professionally recognized standards of care.
What penalty could be imposed by the government for a violation of the False Claims Act?
The False Claims Act, 31 U.S.C. §§ 3729, provides that anyone who violates the law “is liable to the United States Government for a civil penalty of not less than $5,000 and not more than $10,000, . . . plus 3 times the amount of damages.” But how does that apply in practice?
Who enforces the federal False Claims Act?
the Department of JusticeThe suit is filed under seal, so that only the relator and the government know about it. After the suit is filed, the Department of Justice, in conjunction with the local District Attorney, has 60 days to investigate and decide whether to intervene.
How successful are False Claims Act cases?
About 80 percent of all fraud cases won under the False Claims Act are a direct result of whistleblower lawsuits. Whistleblower awards under the Federal law have averaged 17% of recoveries.
The Societal Impact of Medicare Fraud
Sure, it may not seem like this is a huge problem, especially with only 15 total Strike Force cases in the news through half of 2018, but it’s important to realize that many of these investigations involve millions upon millions of dollars. Furthermore, this is money that has essentially been stolen from the U.S.
Individual Effects of Medicare Fraud
For starters, it’s simply maddening to think that individuals who commit these types of offenses are bringing in much more than the typical, hard-working family earns just to survive. For instance, Money reports that the median real income is $54,635 for households in Michigan and $57,259 for a household in Ohio.
Medicare Fraud: Protecting Yourself Begins by Protecting Your Card
According to Medicare.gov, you should always “treat your Medicare card like it’s a credit card.” In other words, don’t give the number out to just anybody, because there’s a chance it could be used to open up a fraudulent claim.
Even More Ways to Prevent Medicare Fraud
There are other things you can do to avoid being a victim of Medicare fraud.
What to do if You Are a Medicare Fraud Victim
If you believe that you are a victim of Medicare fraud or if you have unequivocal proof, the first thing you want to do is report it to the authorities. Medicare.gov shares that there are three ways to do this:
Medicare Advantage Fraud
As we have written, the Medicare Advantage program is a hot spot for fraud and abuse.
Medicare Advantage Fraud Will Continue
Nearly 40 percent of Medicare beneficiaries are enrolled in Medicare Advantage Plans today. That equals over 24 million people. This number is only expected to increase. With so many beneficiaries enrolled — and so much money at stake — Medicare Advantage fraud is bound to continue for years to come.
What is Medicare Fraud?
Medicare fraud is a federal crime that costs taxpayers billions of dollars and drags down the efficiency of the health care system. Medicare and Medicaid programs rely upon every doctor’s judgment regarding proper and necessary medications and services prescribed to each patient.
Medicare Fraud Cases Making the News
Last spring, Genova Diagnostics agreed to pay somewhere between $17 million and $43 million to settle allegations the lab sent unnecessary fecal tests to Medicare, Tricare and the federal employee health program in violation of the False Claims Act.
Hospital, Chiropractor Cases Show Range of Medicare Fraud
In West Virginia, a whistleblower will receive $10 million of a $50 million Medicare fraud lawsuit settlement. That case involved allegations that Wheeling Hospital, Inc. paid kickbacks and sent in Medicare claims for unnecessary or improper doctor referrals.
What is the False Claims Act?
A federal law enacted in 1863, the False Claims Act provides individuals the opportunity to file a lawsuit on behalf of the U.S. government and to receive a portion of any successful lawsuit or monetary settlement. Such a lawsuit is called a qui tam action. The person who initiates the qui tam action is known as the relator. The U.S.
Billions of Dollars in Fraud
According to the Centers for Medicare and Medicaid Services (CMS), the estimated total of improper payments made by Medicare in 2019 alone was about $28.91 billion, which amounted to approximately 7.25% of the total amount paid.