Articles Posted in Whistleblower Lawsuits

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

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

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

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

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

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

Six years after Hunter Laboratories acted as a whistleblower to file a Medicaid Fraud Lawsuit against eight medical testing lab companies for allegedly overcharging California’s Medicaid programs and giving medical kickbacks to doctors in exchange for patient referrals, defendant LabCorp will settle the case for $49.5 million. In California ex rel. Hunter Laboratories v. Quest Diagnostics, et al, the plaintiff claims that the companies made Medi-Cal pay up to six times more for testing services than it should have so that they could subsidize the discounts that were offered to the hospitals, clinics and physicians for referrals. Other defendants named in this whistleblower lawsuit: Seacliff Diagnostics Medical Group, Specialty Laboratories Inc., Taurus West Inc., Physicians Immunodiagnostic Laboratory, Inc., Whitefield Medical Laboratory, Inc., and Unilab Corp.

In its whistleblower complaint, Hunter Laboratories claims that as a result it could not compete against these lower rates-especially as the discount prices that the larger labs offered were significantly below costs. The California testing lab contends that the by using the Medi-Cal program, which is publicly funded, to subsidize their discounts, the defendants were able to gain ownership of the bulk of the market.

Under California law, providers must bill Medi-Cal the lowest rates, while bribes, kickbacks, and rebates for referral services that Medi-Cal pays for is not allowed. According to the California Attorney General’s office, which investigated the Hunter Laboratories’ whistleblower claims, some of the defendants had engaged in Medicaid fraud for over 15 years.

Recently, defendant Quest settled the Medicaid fraud allegations against it for $241 million. To date, this is the largest recovery made under California’s False Claims Act.

Whistleblower Lawsuits
If you believe that you have grounds for filing a Whistleblower lawsuit on behalf of the federal government for fraud committed against it, you should speak with an experienced Massachusetts whistleblower law firm right away. Not only could you end up eliminating fraud committed at taxpayers’ expense, but also you may be able to receive a percentage of the recovery.

LabCorp to pay $49.5M to settle Medicaid fraud suit, Medcity News, July 21, 2011
Read the complaint (PDF)

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

Related Web Resources:
Medi-Cal

Hunter Laboratories

LabCorp
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