Blog
The recent tragic murder of UnitedHealthcare CEO Brian Thompson has provoked conversations about insurance companies' refusal to approve and pay valid claims for important healthcare services. While the shooter's actions were totally indefensible, commentators have pointed out that his message strikes a nerve with Americans who are angry with the state of health insurance. Many Americans are all too familiar with the words inscribed on bullet casings found at the scene of the shooting -- "deny," "defend," and "depose" -- because they have been improperly denied coverage for healthcare, or have been forced to expend efforts and resources to gain access to coverage that should have been promptly approved by their insurers.
When routine and deliberate, the improper denial of coverage for medically necessary healthcare can be thought of as part of a systemic fraud on healthcare programs, both private and public. Fortunately, some healthcare programs, especially public programs like Medicare and Medicaid, are protected by robust whistleblower laws that incentivize private citizens to bring the fraud to light. Whistleblowers, particularly those who work within the medical or insurance industries and can see fraudulent schemes first-hand, have an important role to play in rooting out this kind of fraud. The brave conduct of whistleblowers can actually force changes in our healthcare system, not through violence or other unlawful behavior, but through legal action. Here is how whistleblowing can help bring about change.
Types of Fraudulent Health Insurance Schemes
Fraudulent health insurance schemes can take numerous forms. For example, an insurance company may outright deny coverage of necessary treatment. There is nothing more frustrating for a patient than when their insurance company improperly denies coverage for medication or procedures that the patient's doctors deem medically necessary. Health care providers are often equally frustrated, and outraged.
Similarly, insurance companies may implement improper utilization review. Unscrupulous insurance companies sometimes apply improperly strict criteria in their utilization review process to deny in-patient admissions, or to deny or delay medically necessary treatment for patients, despite clear medical necessity. Doctors and hospitals are left to handle sick patients differently and less effectively than they should, and patients suffer.
When patients are covered by a government program like Medicare Advantage or a Medicaid managed-care program, and the improper refusal of care is deliberate and systemic, the insurance company may be liable under the False Claims Act or similar federal or state whistleblower statute. That is because Medicare Advantage plans, and similar managed care plans under Medicaid, accept government funds that are meant to cover their Medicare Advantage members for all their medical care, regardless of pre-existing conditions and health status. If those same plans then systematically deny coverage to their members, they are effectively keeping government funds as profit that should be used for their beneficiaries' medical care. Knowingly denying coverage for a medically necessary service is essentially submitting a false claim to the government program by not paying for a service that should have been covered.
Reporting Fraudulent Health Insurance Schemes
While the denial of an insurance claim is of course not always a sign that a company is committing fraud on the government, it is important to pay attention to denials of coverage for care over time and across many patients, particularly if that care is clearly medically necessary or involves an extended stay in a hospital. If you work in healthcare and have observed insurance companies deny coverage to patients on a Medicare Advantage or Medicaid managed-care plan when you believe the patient should have been covered, you may have witnessed fraud on the government.
People who have substantial information about potential fraud on the government can act as "relators" under the False Claims Act. A relator is a type of whistleblower who files a case alleging fraud in the name of the United States government. If it is ultimately determined that a company committed fraud on the government, that company must pay three times the amount of money it received in false claims, in addition to other penalties. The relator then keeps between 15% and 30% of those damages.
Relators are sometimes healthcare professionals who have observed insurance companies deny coverage for medically necessary care to patients on government health insurance programs. Several states also have whistleblower reward programs that cover fraud on private health insurance. And a recent Department of Justice whistleblower program highlights private insurance fraud as one of its focuses.
Contact The Expert Whistleblower Attorneys at Goldberg Kohn
Fraud on government and private health insurance programs interferes with the effectiveness of such programs and it harms patients by creating additional barriers to receiving vital healthcare. The attorneys at Goldberg Kohn are committed to fighting fraud on the government and to helping ensure government health insurance programs serve their intended purpose of making healthcare more accessible. We also have a track record of helping our clients get successful settlements and obtain favorable court orders. If you believe you have information about fraud on a government health insurance program, please contact us.