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. " »

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" »