The Federal False Claims Act and Ventura Health Care Fraud Claims
Healthcare fraud is one of the leading types of fraud that the US Department of Justice handles when it pursues violations of the Federal False Claims Act (FCA). The FCA, which dates back to the days of President Lincoln, gives the federal government the right to seek repayment from anyone who improperly bills government agencies. A main feature of the FCA is that whistleblowers, people who disclose the fraud, are entitled to a percentage of any recovery, if the whistleblower qualifies. The percentage can be as high as 30%. The amount of the recovery includes statutory fines which means that many whistleblowers have received awards of a million dollars or more.
Our Ventura California employment lawyers explain the disclosure requirements and how the litigation process works. We fight to get whistleblowers every dollar they deserve.
Agencies involved in healthcare fraud
The US Department of Justice files False Claims Act cases on behalf of agencies that have been taken advantage of by the contractors who submit bills to them. The government depends, in healthcare fraud cases, on doctors, nurses, suppliers, technicians, and anyone with knowledge of fraud to disclose the fraud to the Justice Department, through their lawyer. The healthcare agencies that the US DOJ represents include:
- Tricare – the government agency for retired military personnel and their families
- Medicare Part D
The ways healthcare providers try to cheat the government
Doctors, hospitals, pharmacies, drug manufacturers, and others submit false claims in many different ways. Some of the more common ways are:
- Submitting bills for services never rendered
- Creating ghost patients
- Upcoding – using a code that results in a higher payment than is justified
- Order services that aren’t necessary
- Inflating the costs of overhead
- Providing false certifications
- Red-lining – favoring healthy patients over non-healthy patients when the amount that can be billed isn’t based on the time spent with the patient
Big pharma fraud
Some drug manufacturers try to pressure or provide incentives to the doctors and hospitals that prescribe medications. Medications should always be prescribed based on patient care and not physician profit. Some of these incentives which justify an FCA whistleblower claim include:
- Off-label marketing. Doctors are required to sell their drugs only after FDA approval and according to approved FDA labels for usages. Doctors have broader discretion – they can prescribe off-label uses for their patients. Drug makers are not allowed to pressure or induce doctors to prescribe their drugs as a way of getting around the label requirements.
- Violations of best practice requirements. Drug makers must offer Medicaid the best price (no higher than what they charge private companies) for their drugs. Some companies say they’re offering the best price to Medicaid but then sell the drugs to private companies for less
Big pharma fraud also includes violating the good manufacturing requirements of the FDA.
Many drug makers have already been forced to pay millions to the US Department of Justice for these illegal schemes.
Stark Law provides that doctors (or family members of doctors) who have a financial interest in a facility such as a lab testing procedure or another medical office cannot refer patients to that facility unless a valid exception applies.
The Anti-Kickback Statute (AKS) provides that doctors, hospitals, and other health providers cannot accept incentives in order to get the provider to refer a patient to someone who gave the incentive. – unless a safe harbor applies.
Both laws apply to Medicare and Medicaid. The AKS also applies to other federal agencies. There are similarities and differences between the two laws. The key thing whistleblowers need to know is that a violation of either law is also generally considered to be a violation of the False Claims Act.
Research and development fraud
Universities and private businesses depend on government grants and federal tax credits to finance their research. When these schools and companies take advantage of the kindness of the government to help fund their research, a False Claims Act case is justified. Examples of R&D fraud include:
- Submitting false information on the grant application
- Falsifying the date or the research results
- Overbilling for costs
- Not using the grant funds for the research
- Not meeting federal safety protocols
Our Ventura False Claims Act lawyers are experienced employment lawyers. We work to protect the rights of workers in many ways including their right to disclose fraud by their employer. If you are aware of any fraud by an employer or by a company you work with, call the experienced Ventura law offices of Stephen Danz & Associates. We’ve been fighting for justice for nearly four decades. Our phone number is (877)789-9707 or you can complete our contact form to make an appointment. Se habla espanol.