February 12, 2013

Legal Rights for Employees Who Report Fraud in Hospitals & Nursing Homes

by Levin & Perconti

Healthcare costs are a hot topic these days (and everyday for the past many years). At one point or another virtually everything under the sun has been blamed for rising costs-from lack of insurance to lawsuits. Unfortunately, receiving far too little attention are the incentives of medical care providers themselves to ensure that prices go up and the quantity of medical care provided is as high as possible.

With pay per service medical care, there is an incentive for medical facilities to provide more can than a patient may need in order to receive payment for that care. This is not a condemnation of medical providers but a concession to the obvious reality that when a business is paid to provide a service, the business has incentives to increase the need for the service. When it comes to medical care, that means increase the need for certain treatments, tests, procedures, or other care.

Because of that inherent situation, it is critical for observers to put systems in place to prevent abuse of those financial incentives. Taxpayers are ultimately the ones who foot the bill for much medical care (via the Medicare and Medicaid programs), and they are the ones who suffer when medical facilities violate rules and take more in payments than necessary.

Medicare & Medicare Fraud - Whistleblower Suits
One of the ways in which possible fraud is guarded against is through the federal False Claims Act. The federal law has "qui tam" provisions which are more commonly known as "whistleblower" lawsuits. Essentially, under the law, when a private individual with knowledge of violation of the law comes forward and presses for accountability, that individual may receive part of the sum recovered that was given fraudulently.

In the medical setting, these whistleblower lawsuits can take many forms. For example, some of the most common examples of fraud relate to billing. "Upcoding" is a common problem where a facility sends bills to the government for care provided at a rate that was higher than necessary. In other cases the billing amount might be correct, but the underlying service provided might not be necessary. Providing care that is not needed may be an example of fraud.

Whistleblower Cases in Other Settings
Hospitals are just one setting where whistleblower lawsuits might be pursued by local residents. For example, nursing homes receiving money from Medicare or Medicaid may also violate the law. These facilities might bill for services that are not needed or even bill for services that are not provided. Similarly, other medical caregivers, like hospice providers, may engage in practices in order to take more money from federal coffers than necessary. In those cases, fraud may have been committed, and anyone who comes forward to share information could receive part of the funds recovered.

If you or someone you know may have information about these practices, it critical to get in touch with a legal professional today. Attorneys who work on whistleblower lawsuits can explain how the law might apply in your case and provide tailored advice on the best way to pursue the matter. There is no cost or obligation from contacting a professional today to learn more.

See Other Blog Posts:

Many Radiology Suits Stem from Mammography Errors

AHRQ on "Never Events" in Hospitals