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.
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:
Officials from Los Angeles County recently announced a settlement with Silver Lake Medical Center, a psychiatric hospital in that city, over allegations that the hospital improperly discharged homeless psychiatric patients to avoid the cost of treating them.
A former Alere Inc. employee who blew the whistle on the medical device manufacturer will receive approximately $5.6 million as a reward. The former senior quality control analyst exposed millions of dollars in false claims against Medicare, Medicaid and other federal healthcare programs.
The Department of Justice has just brought a mammoth case against a Florida compounding pharmacy, two of its executives, and the private equity firm that owns it. The agency accuses the defendants of paying illegal kickbacks to telemedicine doctors and, in some cases, patients, to induce prescriptions for scar creams, vitamins and pain creams without regard for medical need. These prescriptions were then reimbursed by TRICARE, the federally funded healthcare program for military service members and their families.
A former office manager for a Tennessee pain clinic filed a qui tam lawsuit under the federal False Claims Act accusing her former employer of falsely billing Medicare and TennCare for unnecessary painkillers, upcoding claims, and billing Medicare for improper nurse practitioner services. The federal government and the State of Tennessee brought suit and have just settled with a chiropractor, a nurse practitioner and several now-closed pain clinics. As a result of the whistleblower's actions, she will receive more than $246,500 -- a share in the total settlements.
The Department of Justice and a large number of states collaborated on a settlement with dental management company Benevis LLC and over 130 Kool Smiles dental clinics that Benevis provided services for. The clinics and Benevis have agreed to settle allegations of false claims made against state Medicaid programs. The companies allegedly submitted claims for medically unnecessary dental procedures, and procedures that were not performed, on Medicaid-insured children.
Medicare beneficiaries are often required to make a copayment, use coinsurance or pay a deductible when buying prescription drugs. These are collectively referred to as "copays." Congress mandates certain copays, which rise with the expense of the drug, in order to introduce market forces into the purchase of prescription medications. Copays serve both to sway patient choices and to limit what pharmaceutical companies can charge for their drugs.