Articles Posted in Medicaid and Medicare Fraud

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Last month, the Department of Justice announced that it was intervening in a False Claims Act case brought against IPC The Hospitalist Co. Inc., and its subsidiaries (IPC). This most recent case again illustrates the opportunities for corruption and abuse that exist within the health care community.

According to the DOJ, IPC is one of the largest providers of hospitalist service providers in America. It employs 1,400 doctors and nurses in over 1,300 facilities in 28 states.

Hospitalists are doctors who work only in hospitals and other long-term care facilities, such as nursing homes. They oversee and coordinate inpatient care at these various facilities.

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The Medicare program is a vital support system for seniors in the United States. The health care program ensures that all elderly community members have access to the care they need to deal with the medical ailments they face. Of course, as with all insurance coverage, there are various rules which dictate when one qualifies and what specific care is paid for under the program.

For example, there remains much confusion regarding the long-term care that is or is not provided to Medicare recipients. Most notably, it is Medicaid, not Medicare, that provides long-term nursing home coverage. If a senior reaches the point where it is not safe for them to live in their own home, they usually need to have Medicaid coverage to receive federal support for a move into a nursing home.

But that is not to say that Medicare provides zero payments for nursing home stays. Instead, Medicare’s coverage is more limited, intended only to pay for rehabilitative stays, usually only lasting a few months. These rehab stays are thought of as connected to actual medical care as opposed to the more permanent living arrangements of some in long-term care facilities.

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Medicare and Medicaid fraud remain a huge problem nationwide. It is an issue that affects all taxpayers, as it essentially represents outright theft of the state and federal governments that we all fund. The fraud take on many forms but, in general, involves cases where providers bill the government for medical care that was not provided, was not necessary, or was not done adequately. This fraud results in tens of billions of dollars being drained from public coffers.

Unfortunately, the problem is notoriously difficult to detect, because it is usually perpetrated by individual doctors, administrators, and other health service providers in positions of trust. There are not nearly enough resources to provide sufficient outside audits to identify the problem. And even then, there are ways to cover up the fraud even from investigators.

For these reasons, most Medicare and Medicaid fraud only comes to light with those with inside knowledge come forward and explain what is going on. In fact, the law has built in incentives to encourage this conduct, providing whistleblowers with a portion of any funds recovered as a result of their stepping forward.

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A private healthcare system has one inherent conflict–money. When individual caregivers and facilities receive payment for the specific services they render, and patients almost always agree to the doctor’s recommendations about needed services, there is a risk of medical decisions being influenced by a drive for profit.

Recognizing this reality is not an automatic indictment of any specific caregiver. But, at the very least, it is critical that we recognize this risk and take steps to guard against it.

Chicago Medical Malpractice & Fraud

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How do you prove your doctor committed medical malpractice? What specific evidence may be used in the case to convince a jury of what happened?

Every case is different, but in general, all of this information is collected by a plaintiff’s attorney via the “discovery” process. As the name implies, discovery is the part of the civil lawsuit process where both sides interview relevant parties (depositions), request access to documents that each side possess, and otherwise gather evidence to be used in a potential trial. It is hard to overestimate the importance of the discovery process. It is often the crux of any medical malpractice lawsuit–where the truth about what happens truly rises to the surface.

Unfortunately, for the same reason that this process is so critical uncovering misconduct, those who are often held responsible for misconduct–large corporations–are working to limit the discovery process.

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Some stories of chronic malpractice are almost too shocking to believe. That description fits the case of one surgeon (now “former” surgeon) who faces lawsuits from an eye-popping 250 former patients for a variety of claims. The plaintiffs in those case allege that the doctor botched their surgeries, performed work that was unnecessary and, in some cases, literally faked the procedure–pretending to work while actually doing nothing.

World’s Worst Orthopedic Surgeon?

According to a helpful report from Yahoo News, the doctor in question was an orthopedic surgeon who worked for several years at a medical clinic. His 250 acts of malpractice allegedly took place over a period of years, from 2007 to 2011. As is common in these medical arrangements, the doctor was employed by a medical clinic but actually performed many operations at a local hospital.

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We often explain how medical malpractice cases refer to civil lawsuits where an injured party (or their family) is seeking financial accountability for the consequences of medical errors. Because they are civil lawsuits, they are filed between two private parties, which can include individuals, businesses, or even public entities. Our medical malpractice lawyers in Chicago work on these cases.

In rare situations, at the same time that civil lawsuits are filed, a negligent professional may also face criminal charges. These are separate but concurrent legal matters. They do not involve one private party suing another. Instead, as in all criminal cases, it is technically the society as a whole (represented by a prosecutor) seeking accountability against someone who broke a criminal law. While the individuals directly affected by the criminal conduct may have a personal interest in ensuring criminal accountability, they technically are not a party in any criminal case.

Perhaps the most high-profile recent example of a case of malpractice against a doctor that resulted in criminal liability is that of Dr. Conrad Murray–the former personal doctor to Michael Jackson. Murray was convicted of committing crimes because his improper conduct was so obviously wrong–dispensing medication recklessly–that it rose above mere negligence.

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Few policy issues are fraught with more confusion, complexity, and disagreement that health care costs. Many argue that ballooning state and federal budgets are driven by the rise in healthcare costs being borne by governments. This is mirrored in rising healthcare insurance premiums being paid by individual community members.

There is little disagreement regarding the fact that costs are rising, but there is considerable misunderstanding about why they are rising and what should be done to turn things around.

Some ideas have been shown to be red herrings, like enacting tort reform laws to limit the rights of medical malpractice victims. Beyond having serious consequences on patient safety efforts, these legal changes do nothing to impact costs.

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Doctors perform perhaps the most important tasks of any professional: keeping us healthy. Considering the magnitude of their work, all medical care providers are held to high standards, as the consequences of mistakes are as serious as it gets. Quality patient care must be the priority at all times, and nothing can be allowed to get in the way of that.

Yet, time and again some medical care providers place profits over patients. Instead of making all decisions based on the best interest of those who are relying on them, these parties look first to their own bottom line. It even happens here in our neck of the woods

Problems at Sacred Heart

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When reading about the case against Dr. Michael J. Reinstein in Chicago, most community members understand in general terms what was going awry. All medical decisions, whether at the hospital, nursing home, clinic, or elsewhere need to be made with the best interests of the patient in mind. When other factors influence the decision (i.e. money), then the process has broken down.

But how does this sort of conduct implicate legal issues? In Dr. Reinstein’s case he is alleged to have over-prescribed a certain dangerous medications for his own personal gain–he was paid by the makers of the drug to push the product. But, it isn’t as if the Doctor intentionally harmed patients, and in certain cases the patients may actually have benefited from clozapine. Most understand how incredibly inappropriate and potentially harmful this conduct is, but the legal underpinning of the lawsuit related to these issues is less well known.

False Claims Act