Upcoding & Unbundling In Healthcare Fraud
What Is Upcoding?
"Upcoding" occurs when a healthcare provider knowingly submits a claim with an incorrect billing code in order to increase reimbursement. A healthcare provider can do this by submitting Current Procedural Terminology (CPT) codes for lengthier, more expensive, or more serious procedures, equipment, or diagnoses than actually provided. For example, if a physician exaggerates the severity of their patient's condition in order to increase billings, that would be considered upcoding. Likewise, if a patient receives a brief consultation from a nurse, but the provider submits a claim for a higher cost consultation with a doctor, that would also be considered upcoding. More
Higher Education Incentive Compensation Fraud
The U.S. government invests in colleges, students and universities by contributing to university endowments, offering scholarships, providing grants, and guaranteeing student loans. Since taxpayer dollars are used to support colleges and universities, the government imposes strict rules to prevent fraud in higher education. For example, the Higher Education Act (HEA) prohibits universities from paying incentive compensation to recruiters or employees based on the number of students they are able to recruit. More
The Anti-Kickback Statute and the False Claims Act: Working together to promote the responsible use of government funds
What is the Anti-Kickback Statute?
The Anti-Kickback Statute ("AKS")1 is a federal criminal law that prohibits the knowing exchange of valued items, services, or payments for referrals of goods or services reimbursable by federally funded healthcare programs. Any claim submitted in violation of the AKS is false, and therefore not reimbursable by federally funded healthcare programs. Accordingly, the AKS seeks to ensure patient health considerations drive medical decision-making, rather than monetary or other valuable incentives offered to providers. Combined with the False Claims Act ("FCA"),2 which allows individuals to sue parties who defraud the government, the two statutes provide a potent tool to combat health care fraud. More
Qui Tam Lawsuits
What Is A Qui Tam Lawsuit?
The term qui tam originates from a Latin phrase that means "[he] who sues in this matter for the king as well as for himself." As such, a qui tam lawsuit is a type of civil lawsuit whereby a private individual, or a relator, with knowledge of fraudulent activity, assists in filing a case on behalf of the government. Qui tam lawsuits are filed under the False Claim Act and, in the event of a successful case, a relator receives as a reward a part of the funds recovered by the government. More
Famous Whistleblowers and Their Impact on America
Whistleblowers have played a vital role in American history, bringing to light abuses and scandals in fields as diverse as pharmaceuticals and the military. Law enforcement agencies and government departments depend on whistleblowers to alert them to corporate and government corruption. That doesn’t always mean these entities have welcomed whistleblowers, however, especially when those people are highlighting problems within their organizations.
Fortunately, federal and state legislatures have enacted protections for whistleblowers, understanding the fundamental role they play in a democracy, and whistleblowers continue to come forward with valuable information about government and corporate misdeeds. Let's examine some of the most famous whistleblower cases and the role these courageous men and women have played in our nation's history. More
New Formal Guidelines on "Cooperation Credit" for False Claims Act Defendants
The Department of Justice released formal guidelines on May 7, 2019 allowing False Claims Act defendants to receive "credit" by taking steps to cooperate with an ongoing government investigation. The goal of this guidance is to incentivize companies to provide meaningful assistance throughout a DOJ investigation, including voluntarily disclosing misconduct that may not be within the scope of any pending investigation. Although the impact of the formal guidance on False Claims Act cases is still unclear, there is some possibility that cases will resolve more quickly due to increased cooperation by defendants. More
Failing to Meet Cybersecurity Requirements May Expose Company to False Claims Act Liability
Recent developments in a case heard by the U.S. District Court for the Eastern District of California shine a spotlight on the importance of cybersecurity measures for government contractors. The district court denied in part a motion to dismiss from defendants Aerojet Rocketdyne Holdings, Inc. and Aerojet Rocketdyne, Inc. (collectively, "Aerojet"), holding that the relator "plausibly pled that defendants’ alleged failure to fully disclose its noncompliance [with cybersecurity requirements] was material to the government’s decision to enter into and pay on the relevant contracts." [1] More
Carolina Physical Therapy and Sports Medicine, Inc. Settles False Billing Allegations and Agrees to Pay $790,000
US Attorney Sherri A. Lydon announced on May 9 that the United States Attorney's Office for the District of South Carolina has resolved claims of health care fraud with Carolina Physical Therapy and Sports Medicine, Inc. ("Carolina PT"). Carolina PT had nine physical therapy practices in South Carolina, in Columbia, Irmo, Lexington, Sumter, and Mount Pleasant respectively. More
Pharmaceutical Executive Found Guilty of Racketeering Conspiracy in Landmark Bribery Case Involving False Claims
On May 2, Insys Therapeutics ("Insys") founder, John Kapoor, and four co-defendants were found guilty of a racketeering conspiracy for running a nationwide bribery scheme involving the over-prescription of opioids. Kapoor is among the highest-ranking pharmaceutical executives to be held responsible and face trial for their part in the opioid crisis. The charges carry up to 20 years in prison. More
Government Takes a Hard Line on Fraudulent Donations to Patient Assistance Programs
Last month, the Department of Justice ("DOJ") announced a settlement with two pharmaceutical companies – Astellas Pharma US, Inc. ("Astellas"), and Amgen Inc. ("Amgen") – resolving allegations that their "donations" to patient assistance programs violated the False Claims Act. The two companies agreed to pay a total of $124.75 million, and both entered into five-year corporate integrity agreements with the Office of Inspector General as part of their respective settlements. United States Attorney Andrew E. Lelling said that according to the allegations, the companies illegally subsidized the high costs of their own drugs at the expense of American taxpayers, and "[w]e will keep pursuing these cases until pharmaceutical companies stop engaging in this kind of behavior.” Multiple settlements related to similar investigations have already brought in hundreds of millions of dollars in only a few years' time. More
Subscribe to this blog's feedRecent Posts
- Upcoding & Unbundling In Healthcare Fraud
- Higher Education Incentive Compensation Fraud
- The Anti-Kickback Statute and the False Claims Act: Working together to promote the responsible use of government funds
- Qui Tam Lawsuits
- Famous Whistleblowers and Their Impact on America
- New Formal Guidelines on "Cooperation Credit" for False Claims Act Defendants
- Failing to Meet Cybersecurity Requirements May Expose Company to False Claims Act Liability
- Carolina Physical Therapy and Sports Medicine, Inc. Settles False Billing Allegations and Agrees to Pay $790,000
- Pharmaceutical Executive Found Guilty of Racketeering Conspiracy in Landmark Bribery Case Involving False Claims
- Government Takes a Hard Line on Fraudulent Donations to Patient Assistance Programs
Topics
- Ambulance Fraud
- Circuit Court Opinions
- Corporate Fraud
- Cost-Plus Contracts
- Criminal Fraud Charges
- Department of Justice
- Evidence
- Farm Subsidy Fraud
- Goldberg Kohn
- Grant Fraud
- Healthcare Fraud
- Higher Education
- Housing and Urban Development
- Kickbacks
- Legal Procedures
- Legislation
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- Medicaid
- Medical Devices
- Medicare
- Military & Defense Fraud
- Nursing Home Fraud
- Pharmaceutical Fraud
- Price Gouging
- Qui Tam
- Real Estate Fraud
- Rule 9(b)
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- Tax Fraud
- Unnecessary Medical Services and Procedures
- Upcoding
- Whistleblower Awards
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- White House