The False Claims Act allows private parties -- often the employees of companies that contract with the government -- to file lawsuits on the government's behalf. When these whistleblowers have evidence of fraud, waste or abuse in a government contract, they can sue to help the government reclaim the money. In exchange for their service, the whistleblowers receive between 15 and 30 percent of the total recovery as a reward.
"Patients and taxpayers rightly should expect that referrals be based on sound medical judgement, not driven by thinly veiled bribes, as alleged here," said a spokesperson for the U.S. Department of Health and Human Services Office of Inspector General.
Between 2006 and 2017, according to the Justice Department, Walgreens Boots Alliance, Inc., billed Medicare, Medicaid and other government healthcare programs for hundreds of thousands of insulin pens that it knowingly dispensed to people who did not need them. The nationwide pharmacy has agreed to pay $209.2 million to settle the government's claims.
As drug prices rise in the U.S., some have expressed concerns that charitable payment of drug copays could be contributing to price inflation. This is because, although most patient assistance groups of this type are charities, pharmaceutical companies routinely donate to the groups.
Vascular Access Centers L.P., along with 23 subsidiaries and related corporations, has been accused of Medicare fraud, violating the False Claims Act, and violating the Anti-Kickback Statute and have agreed to pay at least $3,825 million to resolve the allegations. If certain contingencies arise, additional payments up to $18,360,794 could be triggered.
Medicare Advantage plans are owned and operated by private organizations called Medicare Advantage Organizations (MAOs). Medicare beneficiaries can enroll in and obtain healthcare through these plans. Unlike in traditional Medicare, MAOs are not paid based on services rendered but instead receive a fixed monthly amount for each beneficiary's care. Since some patients require more care than average, payments from Medicare to MAOs are "risk adjusted" to reflect the beneficiary's health status. In other words, MAOs receive higher payments for patients whose conditions require more care.
The federal government intervened in eight False Claims Act lawsuits and brought criminal charges against Health Management Associates, LLC (HMA), a hospital chain that has since been sold. According to the Justice Department, HMA engaged in a scheme to defraud the U.S. The allegations include:
It was an interesting scheme. According to allegations by the Department of Justice, Reliant Rehabilitation Holdings, Inc., wanted to induce or reward its client nursing homes for referring patients to Reliant for rehabilitation therapy. So, it sent over nurse practitioners employed by Reliant to work for those nursing homes for free or below market value.
A Texas doctor will receive $4.9 million as a reward for blowing the whistle on seven ambulance industry defendants who allegedly paid kickbacks to municipal entities in several states in exchange for lucrative ambulance business. The alleged kickbacks violated the federal Anti-Kickback Statute, which prohibits offering, paying, soliciting or receiving remuneration in order to induce referrals. The scheme allegedly resulted in false claims being submitted to Medicare and Medicaid, which violated the False Claims Act.
"When hospices increase their bottom lines by billing taxpayers for unneeded services, they are diverting money from vulnerable, terminally-ill individuals," said a spokesperson for the U.S. Department of Health and Human Services Office of the Inspector General. "Worse yet, these patients may not be receiving care for medical needs that would otherwise be covered in a non-hospice setting."