Healthcare Fraud Attorneys in Salt Lake City
Providing You with High-Quality Legal Representation
While fraud pervades all aspects of government spending, there is one area that has surpassed all others: Health care. By far, the government is the largest single payer of health care dollars to providers, suppliers, pharmaceutical companies, and the like throughout the United States. This was the case before the Affordable Care Act and will remain so. Government programs go by many names and acronyms: Medicare, Medicaid, Tricare, FEHBP, CHIP, HIP, VA programs, ESRD, and many others.
In 2016 alone, over $2.5 billion was recovered in settlements and judgments involving healthcare fraud against the government. The False Claims Act is the government’s primary remedy to protect taxpayer funds from misuse and redress fraudulent claims for government funds and property. Most of these claims are filed under qui tam provisions which allow citizen whistleblowers to bring fraud cases on behalf of the government. If the government prevails in these cases, whistleblowers receive up to 30 percent of the recovery.
Health Care & False Claims
The health care industry is perhaps the most heavily regulated in the United States. The myriad laws and regulations governing the Medicare and Medicaid programs are not all related to being entitled to payment from these programs, but many are. Hospitals, doctors, durable medical supplies and equipment manufacturers, home health care agencies, laboratories, pharmacies, nursing homes, and rehabilitation facilities all may be subject to the False Claims Act – either federal or state.
Any suspected false claims case that touches on the health care industry is extremely complex. These cases require a team of Salt Lake City healthcare fraud lawyers who have expertise and years of experience not only in false claims cases, but also in health care law and finance.
False Claims Act cases arising from the health care industry include:
- Billing for services not rendered or billing for a higher-cost service than actually provided (upcoding)
- Billing for services that are not supported in the medical record
- Diagnostic fraud, i.e., diagnosing a more severe or different ailment than the one the patient actually has, thereby “justifying” a more costly treatment — or making a nonpayable elective procedure into a medically-necessary payable one (diagnostic miscoding or upcoding)
- Knowingly providing false or incorrect data on annual hospital or nursing home cost reports
- Providing materially substandard care. In 2016, the nation’s largest contract therapy provider paid $125 million to resolve claims that it had induced skilled nursing homes to submit false claims to Medicare for rehabilitation services that were not reasonable, necessary, and skilled, or that weren’t provided at all.
- Providing kickbacks (often characterized as contracts with few, if any, services actually required) to a medical provider to induce the provider to send patients to a particular hospital, use certain services (e.g., a particular laboratory), or prescribe certain drugs or use certain products. In 2016, Tenet Healthcare Corp. paid over $513 million for making kickback payments in exchange for patient referrals.
- Having a financial relationship with a doctor who makes referrals (and the relationship is not one covered by an exception to the Stark Law, also known as the physician self-referral law)
- Falsely certifying compliance with federal laws required for payment of a medical claim (usually on claim forms or Medicare enrollment) when the hospital or doctor was not in compliance
Another form of false claim is what has become known as a reverse false claim. In these cases, a person or entity makes a false statement, record, or otherwise takes action to reduce or delay payment of money owed to the government. This situation can arise in many ways. For example, a hospital or healthcare entity may be double paid erroneously by Medicare or Medicaid, or may somehow have a credit balance, which after examination is determined to be owed back to Medicare. Under the False Claims Act, if that money is not refunded within 60 days, it becomes a false claim because the holder of the money is keeping funds it knows are due to the government.
Call us today at (801) 845-9866 to learn more and speak with one of our experienced healthcare fraud attorneys in Salt Lake City.