Boston Injury Lawyer Blog

WellCare Health Plans Inc. has consented to pay $137.5 million to settle four whistleblower lawsuits filed against it over allegations of fraudulent Medicaid and Medicare claims. The health care provider is accused of falsely inflating the amount it claimed to have spent on medical care so it wouldn’t have return the money to Medicaid and programs, including Florida Healthy Kids and Florida Medicaid. WellCare offers managed health care service for about 2.6 million Medicaid and Medicare beneficiaries throughout the US.

The Qui Tam lawsuits also accused WellCare of keeping the overpayments for child care that it got from Medicaid, falsifying information that misrepresented the medical conditions that patients had and were treated for, operating a bogus Special Investigations Unit, manipulating performance metrics related to its call center, and committing marketing abuses.

U.S. Attorney Robert E. O'Neill said the settlement and restitution would go to the state and federal programs that sustained losses as a result of the Medicaid/Medicare fraud. Law enforcement will get the forfeited funds, which will go toward paying for future investigations.

Meantime, the whistleblowers that filed their cases under the False Claims Act should be getting back a percentage of what the US government recovers. For example, according to one Florida newspaper, whistleblower Sean Hellein is expected to receive close to $21 million for helping to instigate the federal government’s probe into WellCare. Hellein was a senior financial analyst at the health care provider when he secretly recorded executives talking about how to double bill for patient services in 2006. If WellCare didn’t spend a certain percentage of the money given to it by the government on care, it was supposed to give back the difference.

WellCare Health Plans whistle-blower to receive about $21 million, Tampa Bay Times, April 4, 2012

WellCare will pay $137.5 million to resolve fraud allegations, TBO, April 3, 2012

More Blog Posts:
$25M Whistleblower Settlement Reached in Hospice Fraud Case Against Odyssey Healthcare Inc., Boston Injury Lawyer Blog, March 25, 2012

Qui Tam Cases Result in $2.B Recovered in 2011, Boston Injury Lawyer Blog, January 4, 2012

Whistleblower Testifies on the Toll Medicaid Fraud Can Take On Patients, Boston Injury Lawyer Blog, December 16, 2011

Whistleblower Lawsuit: Hospice Care Provider Vitas Healthcare Accused of Medicare Fraud, Boston Injury Lawyer Blog, November 27, 2011

Continue reading "WellCare Health Plans Settles Whistleblower Lawsuits in Medicare/Medicaid Fraud Case for $137.5 Million" »

A $25 million settlement has been reached in the whistleblower lawsuit filed by a former nurse employee against Odyssey HealthCare Inc. Per her Qui Tam complaint, submitted in 2008, between 2006 and 2009 Odyssey enrolled and recertified patients who were non-terminal for hospice care, and billed for services that weren’t reasonable or necessary.

Medicare’s benefit, which covers hospice care, is only for patients that are terminally ill. To be eligible for palliative hospice care, a patient must be diagnosed as having six months of less to live.

The plaintiff who filed the whistleblower lawsuit alleging Medicare fraud, Jane Tuchalski, was fired by Odyssey after she expressed concerns about how the hospice care company was run. (She has since settled a separate settlement related to retaliatory termination claim.) Other Odyssey employees also filed their own whistleblower complaints alleging hospice care fraud. While one of the cases was added to Tuchalski’s lawsuit, the other was later dismissed.

Odyssey is now part of Gentiva Health Service, which noted that the allegations of hospice care fraud were for a period of time that occurred prior to its acquisition of the company. Gentiva said that settling the whistleblower case is a reflection of its commitment to making sure compliance is company-wide.

Whistleblower Lawsuits
Because Tuchalski filed her whistleblower lawsuit under the False Claims Act, she is entitled to a percentage of what the government recovers. Also, under the act, employees who are fired for disclosing fraud are eligible to recover double back pay, special damages, and benefits.

In cases when multiple claims are submitted by different employees or others, it is usually the first person to file whistleblower lawsuit that receives the most from the financial recovery. In the hospice fraud case against Odyssey, claimants will get about $4.6 million.

Whistle-blower case on hospice fraud settled for $25 million, JSOnline, March 1, 2012

Hospice Provider Odyssey Healthcare Agrees to Pay $25 Million to Resolve False Claims Act Allegations, Justice.gov, March 1, 2012

More Blog Posts:
Whistleblower Lawsuit: Hospice Care Provider Vitas Healthcare Accused of Medicare Fraud, Boston Injury Lawyer Blog, November 27, 2011

Medicare Fraud?: Cigna, UnitedHealth Group, and Aetna Under Scrutiny for Possible Kickback Violations, Boston Injury Lawyer Blog, November 22, 2011

Pfizer Settles Whistleblower Claim Alleging Pharmaceutical Fraud Related to Detrol, oston Injury Lawyer Blog, October 19, 2011

Continue reading "$25M Whistleblower Settlement Reached in Hospice Fraud Case Against Odyssey Healthcare Inc. " »

The US Justice Department says that 636 qui tam complaints were filed for fiscal year 2011, resulting in $2.8B recovered. Of the more than $3B involving the False Claims Act that resulted in settlements and judgments from fraud cases, $2.4 billion was related to fraud committed against a number of federal programs, including Medicare, TRICARE, and Medicaid. Usually, no more than 400 whistleblower cases are filed annually.

$2.2B was recovered from civil claims made against pharmaceutical companies alone. GlaxoSmithKline PLC agreed to pay $750 million to settle allegations involving false claims related to medications and adulterate drugs that didn’t satisfy FDA specification. $900 million came from drug companies accused of engaging in unlawful pricing to up their profits.

The False Claim Act
Federal and state False Claims Acts cover fraud committed against any state or federal funded program or contract. Since amendments were made to the federal False Claims Act in 1986, the US Justice Department has gotten back more than $30 billion. The amendments provided stronger incentives for whistleblowers to come forward and file lawsuits on behalf of the government. A whistleblower could end up entitled to up to 30% of what the government recovers.

Kinds of fraud that fall under the False Claims Act include those involving:

• Billing for goods the buyer never received
• Billing for services that were never rendered
Falsifying testing data or results
• Falsifying employee records
• Performing unnecessary medical treatments on Medicaid/Medicare patients

Justice Department Recovers $3 Billion in False Claims Act Cases in Fiscal Year 2011, US Department of Justice, December 19, 2011

Qui Tam Action, Legal Information Institute

More Blog Posts:
Whistleblower Lawsuit: Hospice Care Provider Vitas Healthcare Accused of Medicare Fraud, Boston Injury Lawyer Blog, November 27, 2011

Medicare Fraud?: Cigna, UnitedHealth Group, and Aetna Under Scrutiny for Possible Kickback Violations, Boston Injury Lawyer Blog, November 22, 2011

Whistleblower Lawsuit Accuses Florida Hospital of Defrauding Medicare of $2M, Boston Injury Lawyer Blog, November 15, 2011

Continue reading "Qui Tam Cases Result in $2.B Recovered in 2011" »

At a House Oversight and Government Affairs Committee subcommittee hearing earlier this month, whistleblower Richard West testified about how Medicaid fraud affected the quality of care he received. West, who has muscular dystrophy and qualifies for 16 hours of in-home nursing care every day, said he didn’t receive over 700 hours of in-home nursing care for which Maxim Healthcare Services Inc. billed Medicaid more than $20,000. West told the Congressional committee that he thought it was wrong for someone to profit from his disability while stealing from the government.

In 2004, a New Jersey government agency told West that because he had gone above his monthly benefit cap, his Medicaid services had to be suspended or reduced. He complained first to the state and then to Medicaid and later to a social worker but he says that none of them did anything. He then found a lawyer and filed a whistleblower lawsuit. West says that after he took action, he began having problems with getting home health care nurses to come to him even when he fell ill.

A few months ago, Maxim agreed to settle the Whistleblower lawsuit alleging Medicaid fraud for $130 million. This resolves civil allegations both filed by 43 US states and under the US False Claims Act. The in-home nursing care company will also pay a $20 million criminal fine. As part of its deferred prosecution deal, Maxim took responsibility and admitted conspiring to bilk some $61 million from government health programs. Nine people linked to the Medicaid fraud scam have pleaded guilty to criminal charges and the criminal probe is ongoing.

Because the False Claims Act’s Qui Tam provision entitles whistleblowers to a percentage of what is recovered, West’s portion of the award is $15.4 million.

Maxim Healthcare Agrees to a $150 Million Settlement of U.S. Fraud Probe, Bloomberg, September 12, 2011

Patient Whistleblower Exposes $150 Million Medicaid Fraud, ABC News, December 7, 2011

More Blog Posts:
Whistleblower Lawsuit: Hospice Care Provider Vitas Healthcare Accused of Medicare Fraud, Boston Injury Lawyer Blog, November 27, 2011

Medicare Fraud?: Cigna, UnitedHealth Group, and Aetna Under Scrutiny for Possible Kickback Violations, Boston Injury Lawyer Blog, November 22, 2011

Whistleblower Lawsuit Accuses Florida Hospital of Defrauding Medicare of $2M, Boston Injury Lawyer Blog, November 15, 2011

Continue reading "Whistleblower Testifies on the Toll Medicaid Fraud Can Take On Patients" »

In his whistleblower fraud lawsuit, Michael Rehfeldt, a former Vitas Healthcare Corp. manager, accuses the hospice care chain of defrauding the US government. Vitas is a unit of Chemed Corp.

Rehfeldt claims that Vitas and health insurers enrolled patients that weren’t fatally ill in Medicare. He is alleging fraudulent billing and false certifications.

Rehfeldt contends that Vitas allegedly benefited from the scam while breaking rules that prevents patients that aren’t facing death from receiving hospice care. He says that when he told his supervisors about the alleged misconduct, they ignored his concerns. Rehfeldt believes this shows that Vitas executives know about the Medicare fraud.

Meantime, the US Justice Department now wants internal documents from Vitas so it can look into the fraud allegations. The government told the district court that it believes that Vitas defrauded Medicaid and Medicare of hundreds of millions of dollars.

In the last 10 years, the number of patients covered under Medicare through Vitas has doubled to 1.1 million. Although the hospice care company cannot comment on ongoing litigation, a spokesperson for Vitas did say that it has consistently complied with the rules of both Medicaid and Medicare.

Rehfeldt is seeking damages on behalf of the US government. As the whistleblower, he is entitled to part of whatever is recovered over the Medicare fraud. The False Claims Act offers this incentive to get whistleblowers to come forward. He is also suing Care Level Management LLC and WellMed Medical Management in his qui tam complaint.

Hospice Care
In order to qualify for hospice services under Medicare, a patient must only have six months or less to live. Two doctors must certify that this is true. A patient, however, can stay on longer than that as long as his/her terminal diagnosis is recertified every two months.

Whistleblower Accuses Chemed Unit of Medicare HMO Conspiracy, Bloomberg, November 16, 2011

Texas Lawsuit Identifies Problems In Medicare Hospice Provisions, Kaiser Health News, November 16, 2011

More Blog Posts:
Medicare Fraud?: Cigna, UnitedHealth Group, and Aetna Under Scrutiny for Possible Kickback Violations, Boston Injury Lawyer Blog, November 22, 2011

Whistleblower Lawsuit Accuses Florida Hospital of Defrauding Medicare of $2M, Boston Injury Lawyer Blog, November 15, 2011

Pfizer Settles Whistleblower Claim Alleging Pharmaceutical Fraud Related to Detrol, Boston Injury Lawyer Blog, October 19, 2011

Continue reading "Whistleblower Lawsuit: Hospice Care Provider Vitas Healthcare Accused of Medicare Fraud" »

Senate Finance Committee Chair Max Baucus (D, Mont.) and Senator Charles Grassley (R, Iowa) of the Senate Judiciary Committee are looking at whether insurers’ practice of directing tests to specific labs in return for payments or discounts from the labs violate federal anti-kickback laws. This practice is known as "pull through."

Earlier this month, the two senators sent a letter to insurers Cigna, UnitedHealth Group, and Aetna, as well as to clinical labs Laboratory Corp of America and Quest Diagnostics. It was just this May that Quest settled for $241 million a California whistleblower lawsuit with the state. The medical lab testing provider was accused of overcharging California’s Medicaid program for over 15 years and issuing illegal kickbacks to doctors, clinics, and hospitals. This often took the form of discounted rates and free tests for referring patients and other parties to the labs. Even though it agreed to settle, Quest was not admitting to wrongdoing and continued to stand by testing rates. The whistleblower settlement, however, was the largest recovery under California’s False Claims Act. The state is pursuing similar claims against other lab companies.

Pull-through deals have raised concerns for the Human Services Office of Inspector General and the Department of Health. This type of arrangement between a clinical lab and an insurance company violates federal anti-kickback laws, which bar anyone from knowingly and willingly receiving payment for something of value to influence the referral of federal health care program business.

Medicare Fraud
Medicare fraud costs taxpayers billions of dollars annually. Those that work in the industry that choose to expose this type of fraud can be rewarded up to 30% of what the government collects. Filing a Massachusetts whistleblower lawsuit also lets you sue those committing Boston Medicare billing fraud on the government’s behalf.

2 senators probe insurers and labs for possible kickback violations, Amednews.com, November 21, 2011

Quest Diagnostics settles Medi-Cal whistle-blower suit, Los Angeles Times, May 20, 2011

More Blog Posts:
Whistleblower Lawsuit Accuses Florida Hospital of Defrauding Medicare of $2M, Boston Injury Lawyer Blog, November 15, 2011

Pfizer Settles Whistleblower Claim Alleging Pharmaceutical Fraud Related to Detrol, Boston Injury Lawyer Blog, October 19, 2011

Whistleblower in Bank of New York Mellon Corp. Probe to Receive Reward for Helping the Justice Department, Boston Injury Lawyer Blog, October 13, 2011

Continue reading "Medicare Fraud?: Cigna, UnitedHealth Group, and Aetna Under Scrutiny for Possible Kickback Violations" »

A former Boca Raton Regional Hospital has filed a whistleblower complaint accusing the facility’s administrators of purposely using the wrong billing code to defraud Medicare of at least $2M. This was allegedly an attempt to get more government money for treating patients with heart problems.

For now, the US Justice Department has agreed not to pursue a case against the hospital. Jeannette Lavoie, however, has decided to file a Medicare billing fraud lawsuit under the False Claims Act. If her claims prove founded, the Florida hospital could end up paying three times more than what it overbilled Medicare. The act also allows Lavoie to recover up to 30% of these damages.

Lavoie, who served as the hospital’s case management director, says she grew worried that improper reporting was occurring in regards to what procedure heart patients were getting and as to whether these were occurring on an outpatient or inpatient basis. She said that after she expressed her concerns to administrators, they refused to resubmit their bills. They also assumed auditors wouldn’t discover the errors.

Lavoie claims that Boca Raton Regional Hospital turned in over 600 fraudulent claims between July 2006 and January 2009. Meantime, the hospital is denying her allegations and accusing Lavoie of just being out for money.

False Claims Act
The False Claims Act’s “qui-tam” provision lets US citizens file whistleblower complaints on behalf of the government. Unfortunately, Medicare billing fraud is one way others may try to get more money out of the government. Examples of Massachusetts Medicare fraud includes billing for services or goods not provided, conducting tests that aren’t actually needed, up-coding, billing twice for equipment or services, and unbundling.

Lawsuit alleges Boca hospital defrauded Medicare, Sun-Sentinel, November 14, 2011

What is the false claims act?

Medicare fraud

More Blog Posts:
Pfizer Settles Whistleblower Claim Alleging Pharmaceutical Fraud Related to Detrol, Boston Injury Lawyer Blog, October 19, 2011

Whistleblower in Bank of New York Mellon Corp. Probe to Receive Reward for Helping the Justice Department, Boston Injury Lawyer Blog, October 13, 2011

Whistleblower Lawsuit Accuses Southern Care of Charging Medicare While Fraudulently Enrolling Patients in Hospice Care, Boston Injury Lawyer Blog, September 27, 2011

Continue reading "Whistleblower Lawsuit Accuses Florida Hospital of Defrauding Medicare of $2M" »

Pfizer Inc. has agreed to pay $14.5 million to the federal government, the District of Columbia, and 49 states to settle claims that the drug manufacturer not only improperly marketed its bladder control medication Detrol but also cheated Medicaid. The allegations were made by former sales representatives Marci Drimer and David Wetherholt, who filed their Massachusetts whistleblower lawsuit in Boston in 2006 on behalf of the US, 49 states, and the District of Columbia.

Wetherholt and Drimer contended that even though Detrol had only been approved for treating overactive bladders, the company violated federal regulations by promoting it for use that government agency hadn’t been approved, such as for treating impeded urine flow caused by benign prostatic hyperplasia, lower urinary tract symptoms, and bladder outlet obstruction. The two men claimed using Detrol had no therapeutic benefits for some of these conditions.

In their whistleblower lawsuit, Drimer and Wetherholt accused Pfizer of purposely embarked on a path of “unlawful conduct” that it knew would cause pharmacists and physicians to submit thousands of claims that Medicaid didn’t cover. The two men contend that they were pushed out of their jobs by the drug maker after they complained about the marketing practices.

Off-Label Marketing
This type of pharmaceutical fraud involves the marketing of a medication for uses not approved by the Food and Drug Administration that results in a company doing so to get the government to subsidize a medication that it isn’t supposed to cover. Granted, it is not against the law to use medicines for off-label purposes. However, if these prescriptions are billed to Medicaid or Medicare then fraud is being committed.

Under the False Claims Act’s qui-tam provision, which allows for whistleblower awards of up to 30% of what the government recovers, in the wake of their case against Pfizer, Drimer and Wetherholt will get 27% of the federal government’s share of the $14.5 million. They will receive a percentage of the $2.62 million that she states are getting.

Even in settling, Pfizer continues to deny wrongdoing. The company said it chose to settle to avoid the costs that come with litigation.

Pfizer Settles Whistle-Blower Suit Over Detrol Marketing, Bloomberg, October 20, 2011

Pfizer Pays $14.5M To Settle Detrol Off-Label Suit, Pharmalot, October 20, 2011

Related Web Resources:
What is the False Claims Act & Why is it Important?,The False Claims Act Legal Center

Detrol, Pfizer

More Blog Posts:
Whistleblower Lawsuit Accuses Southern Care of Charging Medicare While Fraudulently Enrolling Patients in Hospice Care, Boston Injury Lawyer Blog, September 27, 2011

Massachusetts Whistleblower Lawsuits, Hospice Neglect, and Medicare Fraud, Boston Injury Lawyer Blog, July 26, 2011

Pharmaceutical Fraud May Be Grounds for Filing a Massachusetts Whistleblower Lawsuit, Boston Injury Lawyer Blog, July 23, 2011

Continue reading "Pfizer Settles Whistleblower Claim Alleging Pharmaceutical Fraud Related to Detrol " »

In the wake of securities lawsuits accusing Bank of New York Mellon Corp. of defrauding investors and overcharging them on billions of dollars in currency trades over 10 years, now comes news that the government had been working with a secret whistleblower. Grant Wilson, who worked at the bank’s small trading desk in Pittsburgh, has reportedly been assisting with currency-trading probes into BNY Mellon for the last two years.

Last week, the US Justice Department and New York’s attorney general submitted separate civil lawsuits accusing BNY Mellon of misleading or defrauding public and state pension funds, universities, private companies, and banks with their foreign exchange scam. The US Attorney is also claiming mail and wire fraud. Meantime, the New York Attorney General Eric T. Schneiderman wants the bank to pay up $2 billion for the alleged securities fraud. A spokesman for BNY Mellon denies that clients were given the “least favorable” currency rates.

State attorneys general in Florida and Virginia have made similar allegations against BNY Mellon. They too have filed lawsuits based on the information from Wilson's whistleblower case.

Wilson and the whistleblower group that he belongs to could receive up 25% of whatever BNY Mellon ends up paying for lawsuits stemming for the information he provided. Wilson’s role was kept so secret that the bank’s lawyers never discovered him. He no longer works there.

According to the Wall Street Journal, Wilson kept his involvement a secret by using a shell partnership and holding meetings on the weekends and in different restaurants. In addition to telling attorneys and law enforcement officials about the financial scam and how it worked, he also gave them internal documents that charted BNY Mellon’s profits.

Whistleblower Lawsuits
Filing a Massachusetts Qui-Tam actions , also known as whistleblower lawsuit, on behalf of the government because of fraud that is being committed against it may result in financial recovery for the whistleblower.

Secret Informant Surfaces in BNY Currency Probe, Wall Street Journal, October 12, 2011

The "Secret" Whistleblower at BNY Mellon: How Grant Wilson and his New Partner in No-Crime, Harry Markopolos, Are Changing the Game, Forbes, October 13, 2011

More Boston Injury Lawyer Blogs:
Whistleblower Lawsuit Accuses Southern Care of Charging Medicare While Fraudulently Enrolling Patients in Hospice Care, Boston Injury Lawyers Blog, September 27, 2011

Massachusetts Whistleblower Lawsuits, Hospice Neglect, and Medicare Fraud, Boston Injury Lawyers Blog, July 26, 2011

Pharmaceutical Fraud May Be Grounds for Filing a Massachusetts Whistleblower Lawsuit, Boston Injury Lawyers Blog, July 23, 2011

Continue reading "Whistleblower in Bank of New York Mellon Corp. Probe to Receive Reward for Helping the Justice Department" »

A former SouthernCare employee has filed a whistleblower complaint against the hospice company. Karina Christensen is accusing Southern Care of charging Medicare for hospice care that was given to treat patients who weren’t dying.

In order to have hospice care covered under Medicare, a doctor must have determined that the patient have no more than six months to live before it will agree to cover the costs. Hospice care is focused on helping decrease the severity of the disease’s symptoms during the last months of the patient’s life.

Christensen contends that not only did her supervise encourage this type of fraudulent enrollment in hospice care, but also they disregarded her complaints that this was against the law. Soon after she wrote a letter to the regional director and the board of directors about her concerns in 2010, she was fired from her job. Christensen worked as a clinical director at SouthernCare’s Madison office in Alabama.

Christensen that it would usually be several days after patients were enrolled and Medicare had been charged that she would receive medical information about them. She says that among the patients who were given hospice care was someone who supposedly was dying of cancer but was, in fact, cancer-free. There was also a heart disease patient who exhibited no symptoms of the condition.

SouthernCare, which is a for-profit company that has 75 offices in 15 states, settled similar claims in Alabama in 2009 by paying the federal government $24.7 million. The settlement stemmed from two whistleblower/qui tam complaints submitted by two ex-SouthernCare employees. Per the False Claims Act, which entitles whistleblowers that file lawsuits against parties that defrauded the government to part of the recovery, both women were to receive $4.9 million.

Medicare Billing Fraud
Unfortunately, it is the taxpayers who end up for paying for Medicare billing fraud. Meantime, money that should be treating patients who actually need this care ends up going to the wrongdoers.

Fortunately, the government has established laws to reward and protect those within the industry who come forward and report such wrongdoing. The whistleblower may even be entitled to up to 30% of what the government collects.

Whistle-blower suit accuses hospice company of Medicare fraud, Madison.com, September 14, 2011

Alabama-Based Hospice Company Pays U.S. $24.7 Million to Settle Health Care Fraud Claims, Department of Justice, January 15, 2009

The Federal False Claims Act, TAF.org

More Blog Posts:
Massachusetts Whistleblower Lawsuits, Hospice Neglect, and Medicare Fraud, Boston Injury Lawyer Blog, July 26, 2010

Pharmaceutical Fraud May Be Grounds for Filing a Massachusetts Whistleblower Lawsuit, Boston Injury Lawyer Blog, July 23, 2011

Whistleblowers Expose Medicare Fraud in the Hospice Industry, Boston Injury Lawyer Blog, June 28, 2011

Continue reading "Whistleblower Lawsuit Accuses Southern Care of Charging Medicare While Fraudulently Enrolling Patients in Hospice Care" »